Microaggressions in Clinical Medicine
This paper proposes a victim-centered account of microaggressions within the context of clinical medicine. In so doing, it argues that microaggressions can undermine physician-patient relationships, preclude relationships of trust, and therefore compromise the kind and quality of care that patients deserve. Ultimately, by focusing on the experiences of victims of microaggressions, the paper demonstrates how harmful microaggressions in clinical medical contexts can be, and thus provides strong reasons why healthcare providers ought to know about them and actively work to avoid committing them.
Damon Tweedy is a psychiatrist, lawyer, and writer. He's also Black. While in his first year as a medical student at Duke University, one of his professors approached him in the classroom and asked why the light bulb in the room hadn't been changed, as requested. Tweedy realized that his professor assumed he was a maintenance worker, not a student. Tweedy never took up this incident with the professor, nor did the professor ever apologize. Tweedy recounts that his best "revenge" would be to excel in the class, which he ultimately did. At the end of the semester, upon learning that Tweedy received the second highest grade of over one hundred students, this professor invited him to work as a research assistant in his lab, still never apologizing for what he'd said earlier in the semester. Tweedy declined the professor's invitation. Despite excelling in this class and in medical school, in Black Man in a White Coat (2015), Tweedy discusses how he internalized this incident and how, compiled with countless similar occurrences throughout his education and training, the experience stayed with him. He continually had to battle imposter syndrome1 and try to overturn and disprove stereotypes. This caused him significant stress and anxiety (2015, 24ff). [End Page 411]
Though Tweedy doesn't analyze his experience using the language of microaggressions, this occurrence is a clear example of one. Microaggressions can be defined as verbal, nonverbal, and/or environmental slights, snubs, or insults that are either intentional or (most often) unintentional; they convey hostile, derogatory, or otherwise negative messages to target persons based upon their membership in a structurally oppressed social group (Sue 2010). Over the last decade, and particularly in the last several years, microaggressions have received a great deal of attention, both popular and scholarly, from supporters and critics of alike.2 The most substantial scholarly work on microaggressions analyzes the concept specifically within the context of clinical psychology. One area in which microaggressions haven't been considered in any depth is within the context of clinical medicine.3 Our paper aims to rectify this oversight.4
Section I outlines how microaggressions have been understood within the psychology literature, namely, as microassaults, microinsults, and microinvalidations. This taxonomy distinguishes microaggressions according to the type of act committed by the aggressor. Contrary to this approach, we imagine and propose an alternative way of understanding microaggressions. Instead of taking as the point of departure the act committed by the aggressor, we consider what an account of microaggressions would look like that instead understands them on the basis of the harm(s) suffered by victims. We propose this alternative, victim-centered framework for understanding microaggressions in section II. Our proposed account distinguishes between three different types of microaggressions on the basis of the kind of harm that results for the victim: epistemic microaggressions result in epistemic harms, emotional microaggressions result in emotional harms, and self-identity microaggressions result in harms to one's sense of self, or existential harms.5 In developing our account, we provide examples of each kind of harm that frequently occurs in medical encounters. While our focus in section II is on the harms to patients that can result directly from the microaggressive actions of healthcare workers, section III considers how repeated, long-term experiences of clinical microaggressions can have further damaging consequences: they undermine physician-patient relationships, preclude relationships of trust, and therefore, compromise the kind and quality of care that's received. On the basis of these consequences, we argue that microaggressions shouldn't be ignored in clinical medicine. In order to further motivate and substantiate our proposal to rethink the taxonomy of microaggressions, section IV briefly revisits Sue's account of [End Page 412] microaggressions. In light of two cases considered in section II, we show how and why Sue's account can't derive the precise conclusions about the kinds of harms that result from microaggressions, conclusions that can be reached on our proposed victim-centered approach. On the basis of this conclusion, we suggest that the dominant microaggressions taxonomy ought to be re-conceptualized (though to do so fully falls outside the scope of this paper).
The term "microaggression" was first coined by Chester Pierce (1970) and then developed to refer to the phenomenon of "subtle, stunning, often automatic, and non-verbal exchanges which are 'put downs'" (Pierce et al. 1978, 66).6 In the last decade, there's been renewed and sustained attention to and development of this phenomenon, initially in the work of Derald Wing Sue (2010; Sue et al. 2007; 2008) and more recently by his former student, Kevin Nadal (2013; 2018; Nadal et al. 2011) and others (see Lilienfeld (2017a) a special issue dedicated to the topic of microaggressions). It's widely accepted that "microaggressions" refer to brief and commonplace verbal, behavioral, and environmental indignities—either intentional or unintentional—that are rooted in (implicit or explicit) prejudice and/or racial, ethnic, gender, sexuality, religious, disability, or other stereotypes and that are directed at and subsequently harm members of marginalized groups (see, for example, Sue et al. 2007; Sue 2010; Torres et al. 2010; Nadal et al. 2011; McWhorter 2014).
One example of a microaggression is the following: a person of color is asked "Where are you from?" They respond with, "Louisville, KY, just like you." If, instead of stopping there, the questioner continues, "But where are you really from?" this is a microaggression since it emphasizes that there's an important difference between a white person and a person of color who are both from the United States. Even if unintentional, this line of questioning sends the message that the person of color isn't a "true" American, or that they are (or are considered to be) perpetually a foreigner or "Other" in their own country. Similar messages are sent when people of color, people of lower socioeconomic standing (SES), or people with unfamiliar accents are told, "You speak English well" or "You're so articulate!" Though the speaker might think they're complimenting their interlocutor, such comments suggest that members of these groups aren't expected to be articulate and that their being articulate comes across as surprising and anomalous. When members of these groups routinely hear [End Page 413] such comments and questions, microaggressions can compound to create a sense that they don't belong, even in their birth country.
Sue divides microaggressions into three different kinds: microinsults, microassaults, and microinvalidations. His taxonomy is act-based: microaggressions are understood and delineated according to the kind of act perpetuated by the aggressor. Not only has this taxonomy largely been taken for granted in the growing literature on microaggressions, but it seems to have become sacrosanct. Though Sue has made an undeniably important contribution to the literature on microaggressions, in this paper we'd like to imagine a different point of departure for conceptualizing them. Instead of defining and understanding microaggressions based on the kind of act committed by the aggressor, we focus instead on the kind of harms suffered by victims. Specifically, we propose and begin to consider what such a victim-centered approach to microaggressions might look like. Such an approach accomplishes at least three things that an act-based approach (like Sue's) fails to. It: (1) takes seriously, validates, and puts at the forefront the experiences of victims, rather than perpetrators; (2) ensures that the harms experienced by victims aren't undermined; and (3) makes sure that the various different types of harm aren't missed, erased, or collapsed into a single category.
In choosing to understand microaggressions based on the types of resulting harms, we intend for our proposed categorization both to reflect and to be guided by the experiences of the oppressed. Insofar as we're taking as our point of departure the experiences of victims, one might immediately object that the prefix "micro" isn't appropriate since it seems to undermine the seriousness of harms that result (a problem we address below), and to minimize the agency and responsibility of those committing these harmful acts. For example, from the perspective of the oppressor, to misgender a transgender man or woman might seem like nothing, or, at the very most, like an "honest mistake," something "micro" that can and should just be brushed off. However, when considered from the perspective of the victim, such an act is anything but micro—especially when it's an instance of a patterned experience of being repeatedly misgendered.7 The term "microaggression," then, reflects the understanding of these incredibly harmful actions as small or insignificant, and thus does little to prompt those who commit them to take seriously the severity of harms that result, and also provides little motivation to stop committing them.
Given this problem, one might object further that it would be best to do away with the term altogether and instead to call these acts aggressions, [End Page 414] since from the perspective of the victim, there's nothing 'micro' about them, especially when compiled over time. There are four reasons why we refrain from rejecting the term. First, as it's presently used, the term captures the unique nature and dynamic harm that such aggressions cause: they're at the same time both innocuous (from the oppressor's position) and potentially deeply harmful and enduring (from the position of the oppressed). It's worth holding onto a term that manages to convey, at the same time, both the smallness and the potential severity of the act and harm, respectively. Second, it's important to call attention to these kinds of acts precisely because they're often unintended, which the term "microaggression" seems to capture yet which the terms 'insult,' 'invalidation,' and certainly 'assault' don't.8 Third, it's important to separate these types of actions from those that are deliberate and intentionally racist, sexist, transphobic, etc. Our final reason for retaining the term is that we'd like our discussion to be considered within the growing literature on microaggressions and were we to use another term (or to simply call them 'aggressions,' etc.), this wouldn't be possible.
With a basic understanding of how microaggressions have been understood in psychology, as well as how we intend to rethink them, we ask readers to join us in considering what such a proposed alternative understanding of the phenomenon would look like, specifically within a medical context. Before doing so, an important methodological qualification is in order. In what follows, we discuss a number of different cases. In most of these cases, the authors themselves don't use the term "microaggression" (many were published before this concept gained much traction). Nevertheless, we include these cases since they are clear examples of microaggressions as we understand them, and importantly, they demonstrate how harmful microaggressions can be for the victims.
II. MICROAGGRESSIONS IN CLINICAL MEDICINE AND THEIR RESULTING HARMS
In this section, we consider a possible alternative victim-centered taxonomy for understanding and conceptualizing microaggressions. In lieu of an action-centered classification of microaggressions, the three kinds of harm-based microaggressions that we propose are epistemic microaggressions, emotional microaggressions, and self-identity microaggressions, which result, respectively, in epistemic harms, emotional harms, and existential harms. Before discussing each one, three clarificatory points are in order. [End Page 415]
First, we are focusing on microaggressions within a clinical medical context. We acknowledge that illness itself tends to be accompanied by emotional and self-identity impairing consequences. The point that we'd like to emphasize, however, is that experiences of illness and its impairing consequences are often compounded by harms resulting from microaggressions of healthcare providers and others. That is, whatever harms arise from illness are exacerbated by harms that arise from microaggressions and the resulting failure of healthcare providers and others to take seriously patients' non-physical harms. Thus, harms resulting from microaggressions are significant over and above the consequences brought on by illness.
Second, the three harms (i.e., epistemic, emotional, and existential) resulting from the three different kinds of microaggressions that we propose aren't necessarily clear-cut or analytically distinct. There are often messy overlaps between them: epistemic harms come with existential and emotional side effects and harms to self-identity certainly manifest themselves emotionally as well. Though for the purposes of analysis we separate the harms into three different kinds, for the one experiencing them, such tidy analytic distinctions are rarely possible.
Third, while microaggressions are typically understood to target and affect members of marginalized groups (Sue 2010, 23, 39)—viz., groups that have been historically and systematically oppressed—we understand "marginalization" to have slightly a broader scope. Following Carel and Kidd 2014; Kidd and Carel (2017a; 2017b), we contend that within clinical medical contexts, most (if not all) patients occupy a marginalized position qua patients, relative to physicians, as a result of (temporary or permanent) vulnerabilities with respect to their illness; their general subservience to physicians' demands; their overall lack of (institutional) power and (epistemic) authority; and their (assumed or actual) lack of education and medical expertise relative to physicians within the space of the clinic.9 It's in this respect that even people who are socially dominant in other contexts can still be marginalized—lack power, authority, or status—within the domain of clinical medicine and therefore, on our view, can experience microaggressions in that context. For example, on our account, within a medical context, even an upper-middle class, white, cis-gender, heterosexual man could be subjected to microaggressions based on his marginalized status as a patient. It must be underscored, however, that the microaggressions he might experience in a medical context would have less serious overall consequences than those experienced by [End Page 416] members of other typically marginalized groups, since part of the harm of microaggressions rests on their repeat nature in a variety of different contexts that accumulate over time. Someone who is structurally oppressed is more likely to experience microaggressions in various domains beyond the medical, making the compiled harms more severe.
i. Epistemic Microaggressions and Epistemic Harm
Epistemic microaggressions in clinical encounters are defined as intentional or unintentional/unconscious slights conveyed in speech or gesture by healthcare providers that dismiss, ignore, ridicule, or otherwise fail to give uptake to claims made by patients. Epistemic microaggressions result in epistemic harms to patients, which can result in epistemic injustices, specifically, testimonial injustices. Testimonial injustices are injustices suffered in one's capacity as a knower, which occur when a speaker's claims aren't given uptake by the listener, due to prejudicial stereotypes held by the listener (either consciously or unconsciously) about some facet of the speaker's identity. Epistemic microaggressions are related to—but are not co-extensive with—this phenomenon.10, 11
In medical contexts, epistemic microaggressions involve the tendency of physicians and other healthcare providers to view themselves as experts over patients' bodies in problematic ways. It is true that physicians have a kind of (non-problematic) medical authority over patients; indeed, they're medically trained and technical experts and the reason we visit them in the first place is because they can provide such expertise. This isn't a problem. Rather, the problem is when their expertise prevents them from recognizing, taking seriously, or giving uptake to their patients' claims and to the first personal perspectives that their patients have over their bodies. Though a patient's perspective isn't expert in the sense that most patients aren't trained medical practitioners, their first-person perspectives on their bodies and symptoms that are unavailable to physicians are often crucial in order to help physicians make proper diagnoses.12
Thus, it's problematic for physicians to privilege their own third-personal, objective knowledge of what a patient experiences to the exclusion of the patients' first-personal, subjective, embodied knowledge and resulting testimony. The assumed epistemic privilege of physicians and other healthcare providers over their patients' bodies, experiences, and testimonies can result in microaggressions toward patients, such as implicit or explicit deflation of their patient's credibility or failure to give uptake to their patients' claims. Such microaggressions tend to occur without [End Page 417] healthcare providers being aware that they're committing them. We see an important example of what we are calling epistemic microaggressions in Arthur Kleinman's work, though he doesn't use the term "epistemic microaggressions." Kleinman describes microaggressions in his account of healthcare practitioners discrediting patients' first-personal accounts of their embodied experiences, specifically of patients with chronic pain.
If there is a single experience shared by virtually all chronic pain patients it is that at some point those around them—chiefly practitioners, but also at times family members—come to question the authenticity of the patient's experience of pain. This response contributes powerfully to patients' dissatisfaction with the professional treatment system and to their search for alternatives.
Such failures to give uptake to, to empathize with, or to respect patients as knowers in their own right—often motivated by stereotypes about race, gender, class, sexuality, gender identity, age, or ability—are examples of epistemic microaggressions. Testimonial injustices that result from such microaggressions are harmful to patients in a variety of ways.
As Miranda Fricker (2007) notes, one of the most serious consequences of testimonial injustices are the moral harms committed against speakers (here, patients). The primary moral harm is that speakers are harmed in their capacity as knowers. Being regarded as a knower is a central component of human dignity and value; thus, to be harmed in this capacity results in a violation of the speaker's humanity (Fricker 2007, 43-44). According to Fricker, this primary moral harm leads to a variety of secondary harms, which are either practical or epistemic.
Practical secondary harms that result from patients being harmed in their capacity as knowers include misdiagnoses, which often could have been avoided had the patients' testimonies been taken seriously in the first place. Epistemic secondary harms occur when listeners' doubting of the speaker's testimony is internalized by the speaker, which can result in speakers questioning their own capacity for knowledge. In the case of patients who are victims of repeated epistemic microaggressions, they might begin to doubt their own testimonies and experiences, which can exacerbate emotional and existential harms of the sort we describe below.13
A striking example of what we're calling epistemic microaggressions can be seen in the case of Alan Pean, whose story was featured in both the New York Times (Rosenthal 2016) and on This American Life (Glass 2016). While experiencing a delusional episode, Pean, a young Black male, drove himself to a local Houston hospital to seek psychiatric attention. In [End Page 418] his psychotic state, upon arriving at the hospital, he crashed his car into the side of the building. When he was taken into the emergency room, Pean repeatedly exclaimed: "I'm manic! I'm manic!" Despite expressing multiple times to the healthcare team that he was having a manic episode, and that that was the reason why he was there, he was treated exclusively for the minor physical injuries sustained in his car accident. He was never given a psychiatric evaluation, referred to or seen by a psychiatrist, and importantly for how this story unfolds, he wasn't moved to the psychiatric floor of the hospital.
Pean's claims about his condition weren't taken seriously (epistemic microaggression) which resulted in potentially lethal consequences. But in addition to Pean's own testimony about his mental state not being given uptake by the healthcare team, there are further epistemic microaggressions present in this case. When Pean was first admitted to the hospital, his father, a medical doctor (who, importantly for our analysis, has a thick West Indies accent) and also his brother, who was a medical student, both called the hospital to alert them of Pean's mental state and to request that he receive a psychiatric evaluation upon his arrival. Their requests were similarly dismissed (be it on the basis of race and/or accent); Pean continued to be treated only for the physical injuries sustained in his car accident. His psychological symptoms were ignored. To this end, Pean wound up being given a muscle relaxant for his back pain, a drug well known to exacerbate psychotic symptoms. Consequently, his manic episode escalated. He ended up having an altercation with two armed police officers who were serving as hospital security in the emergency ward (!). Pean's manic symptoms (including delusions and failure to follow instructions) were taken by these authorities to be threats. First, Pean was tasered, but when that didn't subdue him, he was shot in the chest. The bullets missed his heart by only a few centimeters.
To be clear, that Pean was shot is an assault. There's nothing micro about it. Moreover, there are many alarming issues with regards to positioning armed officers in emergency wards; but that's not our present concern. Rather, we're more interested in the microaggressions that lead to Pean being shot in the first place. In Pean's case, the epistemic microaggression occurred well before weapons were drawn. In fact, the racial epistemic microaggression occurred when Pean, a young, Black, male patient, had his testimony repeatedly dismissed by the emergency room healthcare providers.14 Similarly, the requests of Pean's father and brother were also [End Page 419] dismissed. They too were victims of racial, epistemic microaggressions, which resulted in a range of harmful consequences.
Following the categorization of harms outlined above, Pean, his father, and his brother all suffered the primary harm of being devalued as knowers, and thus, were undermined in an important human capacity that's essential for human dignity and respect. Further, Pean faced practical secondary harms of not being treated appropriately in response to his testimony about his mental health.15 He wasn't given the psychiatric evaluation he requested (and needed), nor was he relocated to the psychiatric floor where guards don't carry guns. It was the combination of these two practical consequences that brought about the physical harms of Pean being tasered and shot. Here, the damaging primary and secondary harms of epistemic microaggressions could easily have been avoided had his testimony been given proper uptake in the first place—had the healthcare providers not committed epistemic microaggressions against him (his father and his brother) by failing to listen to them and to give uptake to their claims. Importantly, even in Pean's manic state, he still knew what was best for himself, as did his father and brother. Instead, the healthcare providers took their own assumptions (informed by racial prejudice) to be more credible than Pean's testimony.16
Another example of practical secondary harm resulting from epistemic microaggressions is evident in case of a 19-year-old female patient, Bronte Doyne, who died in part as a result of her physicians' failures to give uptake to her testimony. After expressing concerns to her medical team at Nottingham University Hospitals Trust that her rare form of liver cancer had returned, Bronte's physicians instructed her to "stop Googling" her symptoms. They also failed to diagnose the recurrence of her cancer in a timely enough manner to have enabled her to receive adequate pain management and cancer care (Cara 2015; Srivastava 2015). Doyne ultimately died as a result of her undiagnosed cancer recurrence, 16 months after having her concerns dismissed and being told she'd survive.
Though on first glance it might appear as though this case is simply one of gross medical malpractice, or even of lack of epistemic credibility of the patient, we argue that it's a case of epistemic failure on the part of the physicians resulting specifically from the microaggressions they committed.17 The healthcare providers committed an epistemic microaggression by failing to give uptake to Doyne's claims about her body and symptoms, and in particular her concern that her cancer had returned. In order for us to claim, convincingly, that Doyne suffered a microaggression, we must [End Page 420] first show that she's a member of a marginalized group. Doyne meets this criterion in two ways. First, she's a patient. As mentioned above, following Carel and Kidd (2014); Kidd and Carel (2017a; 2017b), within a clinical medical context, patients can be considered marginalized relative to physicians, insofar as they lack power in the physician–patient relationship. Doyne is also marginalized in a second way, namely, insofar as she's a female patient. It's a known phenomenon that due to pernicious gender-based stereotypes, within clinical medical contexts, women's claims—in particular, claims of pain—aren't taken seriously, are considered to be over-reactions, and are systematically ignored and/or dismissed. As a result, women have diminished status as credible givers of knowledge regarding their bodies (see, for example, Kukla 2005; Foreman 2014b; Code 1991; Dusenbery 2018).
On account of these two different (yet related) ways in which Doyne occupies a marginalized position, it becomes clear that what she experienced were microaggressions. Based on her marginalized status as patient in general and as a female patient in particular, her case isn't just one of medical malpractice or of a failure of attributing epistemic credibility. Rather, the ways that Doyne was treated constitute microaggressions given the nature of the interactions, namely the seemingly small off-hand remarks and slights, such as questioning whether she'd been "Googling her symptoms again," when really, she'd been experiencing physical changes and pain and was trying to make sense of them both to herself and in a way that would receive uptake by her medical team. These sorts of seemingly small comments are examples of microaggressions, and we're suggesting that they're directly tied to Doyne's marginalized status qua female and female patient.
The epistemic microaggressions experienced by Doyne contributed both to serious physical harm (and ultimately, to her death), as well as to significant epistemic harm (and related emotional trauma) for Doyne and her family. The latter can be viewed as a result of their not being listened to, and to their claims pertaining to her medical condition not having received uptake. All of these could have been avoided had Doyne's physicians taken her and her family's claims seriously at the outset.
In this section, we've demonstrated how in addition to the significant physical harms that resulted (at least in part) from these two cases of epistemic microaggressions, both show how epistemic microaggressions can lead to other significant non-physical harms, which are inherently problematic morally and epistemically, and also instrumentally problematic [End Page 421] insofar as they lead to further physical harms. Thus, on account of these consequences, epistemic microaggressions that result in epistemic harms are a serious moral and medical concern. They ought to be on the radar of healthcare providers, who should work to avoid committing them.18
ii. Emotional Microaggressions and Emotional Harm
Illness is often accompanied by a wide range of emotions, many of which arise both before and during clinical encounters and continue to develop in complicated, fluctuating, multi-layered ways with the progression of illness. For instance, patients might react to their diagnosis with disbelief, numbness, sadness, anger, rage, denial, or fear. Emotional microaggressions occur when physicians and other healthcare providers fail to take patients' emotional reactions to and experiences of their diagnoses and illnesses seriously. Emotional microaggressions consist of indignities directed at patients, frequently motivated by assumptions about what constitutes appropriate emotional responses to medical symptoms and diagnoses and often compounded by stereotypes about emotions as they relate to race, sexuality, and especially to gender. Emotional microaggressions, like all microaggressions, can impose additional and serious harms on patients that we discuss in what follows.19
In a 2015 article in The Atlantic, Joe Fassler describes his wife Rachel's emergency room experience, during which both her claims of intense pain as well as her emotional response to that pain were ignored and discredited by healthcare providers. This led to Rachel being misdiagnosed with kidney stones when in fact she had ovarian torsion, which can lead to ovarian loss, sepsis, and even to death. The failures to hear her, to consider her emotional responses to her pain, and the resulting misdiagnosis, led to enduring emotional problems for Rachel, which followed from what she aptly called "the trauma of not being seen" (Fassler 2015).
Despite Joe and Rachel repeatedly expressing the severity of Rachel's pain to the attending physicians and nurses (she rated it an 11 out of 10), each time they were told "she was fine." Two kinds of microaggressions are occurring in this case. The first is an epistemic microaggression, where the speaker's claims to knowledge about their body aren't given uptake, resulting in an epistemic injustice (not our immediate focus here20). The second is an example of an emotional microaggression, where the speaker's emotional response to their pain isn't taken seriously, resulting in emotional harm. [End Page 422]
For the healthcare team to have discredited Rachel's emotional response to her pain is an example of an emotional microaggression. Fassler reports that in response to Rachel's writhing in pain so severe she couldn't speak, nurses barked: "Sit still, or we'll have to start [the exam] over." They also corrected her that what she was really experiencing was "just a little pain." These responses are examples of failures to give uptake to Rachel's claims to pain and additionally to her emotional response to her pain. They are based on stereotypes about women not only being more emotional than men (Code 1991), but also being overly emotional. This tendency to misjudge the seriousness of women's claims about their physical symptoms, especially their pain, is well-documented (see Ellin 2015; Dusenbery 2018; Foreman 2014a; Foreman 2014b; Hoffman and Tarzian 2001; Kukla 2005; National Pain Report 2014; Walters 2016; Watt 2006). It's rooted in histories and stereotypes that women are hysterical, weaker than men, and unable to deal with pain; that they're making it up; that they're seeking attention; or that they're just trying to get their hands on drugs. With respect to chronic pain, Foreman (2014a) documents that healthcare providers are far more likely to dismiss the reality of the pain, and are more likely to treat it as psychiatric in origin (as opposed to physical) (68).
Tara Culp-Ressler details the long history of women's physical symptoms being ascribed to mental pathology, based in stereotypes of women as dramatic, irrational, and crazy (2015). These stereotypes can lead to women being told that their physical symptoms are "all in their head," which can (and often does) lead physicians to miss potentially life-threatening physical conditions, in addition to compounding the emotional distress that the female patients are already experiencing. Considered from the perspective of physicians, one cardiologist confessed that "[i]n training, we were taught to be on the lookout for hysterical females who come to the emergency room" (reported in Dador 2011). This is precisely what happened in Rachel's case. As we show, not only does this tendency to reduce women to "hysterical females" and subsequently to dismiss their claims to pain or other physical symptoms have the potential to do substantial physical harm (especially when it contributes to misdiagnoses), it can also cause lasting emotional harm.
Returning to Rachel's case, it's worth noting that not only did her healthcare team take their own assumptions about her condition to be true (and superior to Rachel's account), thereby failing to consider that Rachel might actually know better than they do about the severity of her [End Page 423] symptoms (e.g., epistemic microaggression); but they also undermined the severity of her emotional responses to her pain. This made Rachel subsequently question whether she was responding "properly" to her pain (as if there is such a thing) and whether she was perhaps being overly dramatic, also contributing to existential harm of diminished self-trust (a consequence we explore below). Presently, we want to show that emotional microaggressions can result in serious and enduring emotional harms to victims, as they did for Rachel. Fassler recounts some of the emotional harms that Rachel experienced, which far outlasted the physical harms of her illness. He writes:
Rachel's physical scars are healing, and she can go on the long runs she loves, but she's still grappling with the psychic toll—what she calls 'the trauma of not being seen.' She has nightmares, some nights. I wake her up when her limbs start twitching.(2015)
The "trauma of not being seen" is what Rachel believes to be the consequence of repeated dismissals of the emotional turmoil brought on by her illness and her emotional responses to her pain. While we want to highlight this emotional harm, we must also be clear that the microaggressions directed at Rachel also resulted in a permanent, practical secondary harm. The medical team's failure to take her claims seriously at the outset (epistemic microaggression) resulted in delayed treatment (she was properly seen more than 14 hours after she arrived at the ER). Though her life was ultimately saved, her ovaries were not. Thus, in addition to the epistemic and emotional harms we've outlined, Rachel also suffered the (practical secondary) bodily harm of losing her ovaries, in addition to the future harm of potentially not being able to conceive children, which she and her partner had wanted to do.
These combined consequences of emotional and epistemic microaggressions are examples of epistemic secondary harms, which result when the cumulative effect and internalization of epistemic injustices over time function to harm one's view of one's self as a competent knower.21 The reality of many members of marginalized groups is determined by understanding and conceptualizing events through the prism of repeated experiences with racism, sexism, homophobia, etc. (Sue 2010, 73). When such experiences are compiled over time, the results accumulate to be more serious and disadvantageous than one might initially assume, what Ron Mallon has called an "accumulation mechanism" (2017). Mallon develops this concept in order to explain how the seemingly small harms [End Page 424] experienced in the past can accumulate over time, amplifying the resulting disadvantage suffered by marginalized individuals or groups (ibid.). Thus, we see that emotional microaggressions that manifest as disregard for patients' complex subjective experiences of pain and illness can be harmful and enduring in a variety of ways. As with epistemic microaggressions, the harmful consequences of emotional microaggressions are serious and therefore ought to be recognized and avoided by healthcare providers.
As we've acknowledged, the distinctions between the types of microaggressions we're considering and their resulting harms are messy. Emotional microaggressions lead to both emotional and existential harms. Robin Stern, author of The Gaslight Effect, describes the phenomenon of "gaslighting," wherein women aren't only shamed for their emotional responses, but their feelings are routinely invalidated through attaching stigmatizing labels such as "crazy" (2007).22 Stern describes the invalidating experience of being "gaslit" as "soul destroying" and argues that women whose feelings are frequently invalidated in this way often start to second guess their ability to make decisions for themselves or conclude that their concerns aren't worth articulating at all (ibid.). In this way, emotional microaggressions that invalidate women's emotional responses to their illnesses and dismiss their physical symptoms as being the result of mental pathology can result in harms that are emotional, existential, and enduring.
Before turning to the final type of microaggressions, a point of clarification. Though we're arguing that patients' claims about their pain and their emotional responses to their physical conditions ought to be given uptake, we don't mean to suggest that all patients should always be the final or absolute authorities about their own diagnoses, or that patients' first-personal knowledge of their bodies, illnesses, or experiences of pain should always or automatically be taken as primary over the medical/ technical expertise of healthcare providers.23 We want to retain important differences between these two distinct types of knowledge: that of patients and that of healthcare providers. Instead of giving priority to one over the other, we suggest the need to take both sources of knowledge seriously when dealing with patients. In her article "Confronting Diminished Epistemic Privilege and Epistemic Injustice in Pregnancy by Challenging a 'Panoptics of the Womb'," (2014) Lauren Freeman argues that within the context of pregnancy, healthcare providers and pregnant people ought to have a relationship of epistemic peers. Epistemic agents are epistemic peers if "they can both make legitimate claims to knowledge about S, and if their respective claims are taken seriously by each of them" (5). Such a [End Page 425] relationship is "based on mutual respect, open responsiveness, and strong communication between women and physicians." Physicians who build such relationships create dialogic spaces in supportive environments, take time to listen carefully to patients' accounts and concerns, and trust that they're credible in their testimony (ibid.). It's this idea of epistemic peers that we have in mind when considering the kind of relationship that should exist between healthcare providers and patients. An epistemic peer relationship lies in sharp contrast to what we see happening in the cases examined above, in which patients' first-hand, embodied knowledges and emotional responses to their illnesses or symptoms are systematically dismissed in favor of healthcare providers' technical knowledge—often with detrimental consequences for the patients.
A related concern is this. One might worry that with the increased availability and use of online resources such as Web MD, patients might attempt to attach incorrect diagnostic labels to themselves, which could be another reason why their perspectives should be treated with suspicion. We aren't arguing in support of these sorts of self-diagnoses; we believe that the ability to diagnose and treat illnesses most often lies within the purview of physicians. The sort of knowledge that we think patients do have isn't about specific medical diagnoses or treatments; rather, it pertains to the types and degrees of pain or other symptoms they're experiencing first hand—things that can't be known (at least directly) by healthcare providers. In cases such as Rachel's, she knew that something was very wrong and she knew that both her claims to pain and her emotional responses to that pain weren't given uptake. It's not, as one might argue, simply a matter of epistemic luck that she just happened to be right about the severity of her pain and her physical symptoms. Rather, Rachel was better positioned to know something about her body than her healthcare team: she had better knowledge of the degree of pain that she was experiencing and she also knew that it was unlike other sorts of pain she'd experienced. This doesn't mean that Rachel was in a position to self-diagnose her ovarian torsion, or to know what treatments were necessary to respond to her pain. The particular sort of expertise possessed by the healthcare providers is crucial to diagnosing and treating patients, and we don't wish to undermine that. Rather, we're suggesting that the ideal scenario would have been for Rachel's healthcare team to have treated her as an epistemic peer. With Rachel's knowledge, combined with their medical/technical expertise, the epistemic, emotional, and physical/ embodied harms she experienced could have been avoided. [End Page 426]
iii. Self-Identity Microaggressions and Existential Harms
The final kind of microaggression we're considering are self-identity microaggressions. News of illness, individual experiences of such news, and illness itself can change how people view and understand themselves and how they relate to others and to the world (Carel 2014). Within medical contexts, self-identity microaggressions occur when healthcare providers (or others, including family members) either intentionally or unintentionally undermine or don't give uptake to the existential consequences that often accompany experiences of illness. Self-identity microaggressions result in enduring, non-physical, existential harms. For example, if physicians and healthcare providers focus only on the physical aspects of illnesses, they might fail to recognize the significance of how experiences of illness can impact the broader ways that patients experience themselves and the world around them, thereby failing to do justice to how important these experiences can be to patients as individuals. It's important to note that while we're highlighting this third category of microaggressions as a distinct source of harm, the other types of microaggressions we've identified in medical contexts can also result in enduring harms to a person's self-identity and self-worth.
An example of an existential harm caused by a self-identity microaggression is illustrated in Anatole Broyard's book, Intoxicated by My Illness (1992). Broyard was a mixed-race man of Louisiana–Creole decent. His memoir documents how his identity was radically altered as a result of his cancer diagnosis and how he desired a doctor who could appreciate that central aspect of his illness experience. Reflecting upon his recently received diagnosis, Broyard writes:
I had dawdled through life up to that point, and when the doctor told me I was ill it was like an immense electric shock. I felt galvanized. I was a new person. All of my old trivial selves fell away, and I was reduced to an essence. I began to look around me with new eyes, and the first thing I looked at was my doctor.(37-38)
With literary and philosophical elegance, Broyard illustrates how he felt deeply affected by his diagnosis. His physician was the first person to whom he looked for acknowledgement and understanding, but Broyard soon realized that his physician wasn't equipped to deal with the existential impacts of his illness. Rather, his physician's role was narrowly focused on the technical aspects of diagnosing and curing an illness, as opposed to seeing and treating a person, a sentiment echoed in numerous patient [End Page 427] testimonies that we reviewed in researching this paper. Broyard reflects on not being seen as a human being by his physician, and how this left him feeling abandoned and alone to deal with his diagnosis.
Other doctors give you a generic, unfocused gaze. They look at you panoramically. They don't see you in focus. They look all around you, and you are a figure in the ground. You are like one of those lonely figures in early landscape painting, a figure in the distance only to give scale. If he could gaze directly at the patient, the doctor's work would be more gratifying. Why bother with sick people, why try to save them, if they're not worth acknowledging? When a doctor refuses to acknowledge a patient, he is, in effect, abandoning him to his illness.(50)
Though Broyard doesn't describe the actions of his physicians and their resulting harms to his personhood using the language of microaggressions, we're calling their actions self-identity microaggressions since they failed to see or engage with Broyard as a human being (rather, they considered his body only as something to be cured) and on an on-going basis, failed to acknowledge or respond to the nature of Broyard's existential difficulties pertaining to his illness that resulted from his vulnerable position qua patient. Though this lack of attention to the more human side of illness might be considered micro from the perspective of the physician—after all, from their perspective, their job is to cure or treat injury, illness, or disease—from the perspective of patients, as we see with Broyard's account, these oversights are anything but micro. The self-identity microaggressions that Broyard faced had serious harmful existential consequences for his well-being and sense of self, as well as for his view of doctor-patient relationships more generally. Broyard recognizes the difference between how he perceives the existential crisis he's facing as a result of his illness, and how his physicians understood it. He writes: "To the typical physician, my illness is a routine incident in his rounds, while for me it's the crisis of my life. I would feel better if I had a doctor who at least perceived this incongruity" (43).
In her article, "Loss of Self: A Fundamental Form of Suffering in the Chronically Ill" (1983), Kathy Charmaz recounts that experiences like Broyard's aren't uncommon. Based on 57 interviews conducted with people living with a variety of chronic illnesses, Charmaz suggests that many chronically ill patients go through significant existential crises as a result of their experiences of illness and the accompanying vulnerability that it brings, combined with failures of their physicians and families to acknowledge the complex existential and psychological [End Page 428] consequences of their illness. Though Charmaz doesn't use the language of microaggressions, we take her to be articulating the harmful existential consequences that arise from self-identity microaggressions, among other things. Charmaz rejects a narrow view of suffering that restricts medical understandings of suffering exclusively to physical harms at the expense of considering how experiences of illness affect one's very selfhood and way of being in the world.
One of the women Chamaz interviews discusses several examples of how harmful self-identity microaggressions can be, especially when they come from someone with whom one has already developed an intimate relationship (like that between a physician and a patient). In describing an incident that happened to her, the interviewee notes the importance of a physician who's more than simply a good technician. She expresses how necessary it is for the well-being of a patient to have a physician who understands their patients as more than a mere body to be cured.
Dr. Lang took care of me—he's okay as a surgeon but as a doctor, he upset me more than words. You keep going in with the same problem and they stop listening. One time he sat there opening his mail while I was in the office. I said, "Go ahead and open your mail, I'll wait." He felt silly, then he listened.(Chamaz 1983, 180)
Later in the interview, the same woman expands upon the importance of a physician recognizing the personhood of a patient:
What I like about Dr. Brenton and Dr. Kaye is that they treat you like a person . . . that is so important when you are ill, to be taken seriously as a person . . . The thing in Dr. Kaye and Dr. Brenton found is a humanitarianism. . . . In a person with chronic disease who has so many things to handle, not only the sickness, but just living problems—to be treated like a number is the last thing you need.(Ibid.)
The physician's act of opening his mail as his patient expresses her concerns about her illness is a self-identity microaggression since this action fails to recognize the human being before him and it had enduring consequences for her self-worth. Throughout her account, we see how harmful it can be to one's sense of self to have their very being ignored by a physician.
Another common example of a self-identity microaggression within a medical context (and more generally) is to deadname, mispronoun, and/or misgender a transgender or gender non-conforming patient. Deadnaming refers to using the birth or legal name of a transgender or gender nonconforming person (that may still be on their legal identification due to [End Page 429] legal, practical, and financial difficulties in legally changing one's name, but that they no longer use). Xeph Kalma, a transgender woman who lives with depression, calls deadnaming "that other dysphoria-spewing beast" (Kalma 2017, 204) and notes that each time it happens she feels like she's "being hit with a hammer" (ibid., 206). She describes her painful experiences of being deadnamed and misgendered in the ER:
Deadnames can be a painful reminder of a terrible time in a person's life. They are tenacious and require resources to fix legally, which many trans folx do not have. Because of this, mine still exists in the legal sense. In an attempt to counter this during the intake process, I tried to make it abundantly clear that even though my deadname might show up on some files, it is not in fact my name and is certainly not how I want to be addressed, especially in a suicidal state of mind. This tactic has worked in the past, but today the message either isn't passed along to the staff treating me or is simply ignored. I'm repeatedly deadnamed, leaving me worse than when I arrived at the hospital. . . . Maybe some years of working in a hospital will have taught them that as a patient, I'm looking to be treated like a human being who is worthy of respect.
It's clear from Kalma's testimony that having her identity undermined was incredibly painful: worse, in fact, than the illness for which she'd originally sought treatment. From the perspective of healthcare providers, deadnaming might seem "micro"; in deadnaming patients, they might not intend to cause harm. However, as Kalma's testimony attests, when considered from the perspective of the patient, deadnaming is not at all micro. Rather, it's an act of profound disrespect, a failure to recognize one's personhood; moreover, it constitutes a failure to listen to or acknowledge patients, and is deeply harmful, in particular when it occurs to a patient already in such a vulnerable state of illness.
When physicians don't give proper uptake to the existential consequences of illness, let alone act in ways that don't recognize the basic personhood of patients (as in deadnaming, mispronouning, and misgendering), they commit self-identity microaggressions; they fail to see and respond to the many significant ways that illness affects individual people, their senses of self, and the ways in which failing to recognize one's selfhood in an already vulnerable state can be exponentially harmful. Insofar as it's common in the face of illness for patients to experience significant existential crises and at times to begin to lose their sense of self, physicians risk harming patients further by not responding appropriately and humanely to these experiences. As the testimonies of Broyard, the chronically ill women [End Page 430] interviewed by Charmaz, and Xeph Kalma show, this can have significant impacts for patients' sense of self and also for how they relate to their physicians. Such harms ought to be avoided by healthcare providers.
III. LONG-TERM HARMS OF MICROAGGRESSIONS IN CLINICAL MEDICINE
In this section we elaborate upon some of the long-term consequences that microaggressions in clinical medicine can have: they can undermine physician-patient relationships, preclude relationships of trust, and therefore compromise the kind and quality of care that is received.
Recall the case of Bronte Doyne, a 19-year-old woman who died as a result of her undiagnosed liver cancer recurrence. She suffered more pain and received less care than she otherwise would have, as a result of her physicians' failures to take seriously her testimony about her symptoms (epistemic microaggression). Consequently, her mother lost trust in healthcare providers. In reference to their repeated attempts to secure adequate cancer care for Bronte, Doyne's mother stated: "I can't begin to tell you how it feels to have to tell an oncologist they are wrong, [but] it's a young person's cancer. I had to. I'm fed up trusting them" (Cara 2015). When microaggressions are repeated, the long-term distrust that can result can have serious and dangerous physical and psychological consequences. Xeph Kalma explains:
In this moment, in my already suicidal state, the doctor has made it a million times worse. I put my coat on and walked out. . . . Instead of having those whom I trust take care of me, those whose job it is to take care of me, I am now at a brand new low—hopeless, hungry, and cold. . . . The way I was treated in the ER—the misgendering, deadnaming, ignorance, and the lack of discretion I experienced—is incredibly dangerous. When I say it was 'my last visit,' I mean it. I will not voluntarily return to an ER the next time I'm feeling suicidal. Anything would be a better option than experiencing that level of embarrassment and shame again. Embarrassment and shame, from those who were meant to take care of me.(2017, 206; our emphasis)
The distrust that results from experiences of microaggressions, as evidenced by the testimonies we've discussed, contributes to patients' doubts about the efficacy of healthcare, often resulting in delayed medical treatment, foregoing medical treatment altogether, and as a result, prolonged illness. These factors can deepen the physical, emotional, and existential harms that accompany illness. Although as we've argued above, all patients could be recipients of microaggressions in clinical contexts, members of marginalized, structurally oppressed groups are more likely [End Page 431] to experience this injustice and to greater consequence.24 One serious and pervasive example of this phenomenon is that many women tend to delay seeking medical treatment when exhibiting symptoms of heart attacks, often because they've internalized a fear of seeming "too emotional," of being dismissed as a "hypochondriac," or as seeming "crazy." A recent Yale study reported that such fears of not being taken seriously led to women having "limited and sporadic connections" with primary care practitioners for routine check-ups and preventative heart care (Lichtman et al. 2015).
Microaggressions are indeed a large part of this structural problem insofar as there's a long history of the sorts of gendered epistemic and emotional dismissals we considered above (even if they have not been called 'microaggressions' until more recently). But this isn't only an issue for cis-gender women. As we saw with Xeph Kalma, a phenomenon that's common for many trans and gender non-conforming folks, fear of being deadnamed and misgendered, is enough to preclude them from even setting foot in a hospital or clinic.25 All of these reactions are related to the problem of microaggressions. Though actions performed may be micro from the perspective of the healthcare providers, the harms suffered are not micro at all and can lead to people avoiding healthcare settings to the detriment of their health.
In one of the two studies of which we're aware that specifically focuses on microaggressions toward patients within medical contexts (Walls et al. 2015), the investigators conducted in-person interviews with 218 adult American Indians diagnosed with type 2 diabetes. They found that greater than one third self-reported having experienced microaggressions in interactions with healthcare providers, which correlated with self-reported history of heart attack, worse depressive symptoms, and prior-year hospitalization. Moreover, the researchers claim that microaggressions, in addition to other kinds of discrimination faced by members of marginalized groups within medical contexts, can ultimately contribute to worse behavior; poorer physical and mental health; decreased service utilization; and reduced treatment compliance (ibid. 233, 237). Decreased service use and treatment compliance can in turn result in further disease complications and comorbidities.
Taking all of this into consideration, our point is this: when one's health, well-being, and in many cases, one's very life are at stake, it's imperative to trust and to have a positive relationship with those in charge of your treatment and care. Experiencing microaggressions within medical contexts, however, can undermine this trust in healthcare [End Page 432] professionals, leading to a variety of roadblocks for successful treatment, as well as serious psychological and existential pain for victims, as evidenced by the testimonies detailed above. We must bring attention to the kinds of microaggressions that arise in medical contexts in order to try to eliminate them (or, perhaps more realistically, to diminish them as much as possible). Working to decrease microaggressions in medicine is especially important in light of the resurgent popularity of the concept of patient-centered care.26 If we truly believe that medicine should be centered around and guided by quality care of patients, then this is all the more reason to promote understanding of health and illness "through the eyes of patients" (Saha et al. 2008). Doing so would involve a commitment to understanding what microaggressions are; recognizing that they occur; understanding the severity of the harms that result from them; and finally, taking steps to be mindful so as not to commit them. As we've shown, non-physical harms within the context of illness can be just as serious as (and sometimes, as in the case of Rachel, even more enduring than) physical harms. As such, medical practitioners need to take heed and work to reduce microaggressions.
IV. MICROAGGRESSIONS REVISITED
In the preceding sections, we've proposed and begun to develop a victim-centered alternative to Sue's action-based account of microaggressions. We now return to several cases to show how and why our account yields a better understanding of the specific harms of microaggressions than can be obtained on Sue's. In so doing, we hope to demonstrate the theoretical and practical value of a victim-based account of microaggressions and to motivate further discussion on this topic.
Though Sue's account of microaggressions is useful for delineating actions committed by those with relative power to members of marginalized groups, it's less helpful in determining the precise nature of harm suffered by victims as a result of those actions. A victim-based account is better suited to this task. In order to demonstrate this point, we return to the cases of Alan Pean (epistemic microaggression) and Xeph Kalma (self-identity microaggression).
Recall that Pean's claims about his psychological condition were repeatedly ignored by healthcare providers, which led to a series of harmful consequences, including the failure to provide him with necessary psychiatric evaluations or care, which could have prevented his being tasered, shot, and almost killed. On Sue's account, Pean would likely [End Page 433] have experienced a racial microinvalidation, defined by Sue et al. as "communications that exclude, negate, or nullify the psychological thoughts, feelings, or experiential reality of a person of color" (2010, 274). Pean's claims were ignored (due to racial stereotypes held by healthcare providers), thereby invalidating him as a person. Though calling this harm a microinvalidation captures very generally the basic harm suffered by Pean—nobody likes to be ignored—labeling it a microinvalidation fails to capture the precise and important epistemic dimension of the harm, which is a crucial component both of the case and of the enduring epistemic consequence of such microaggressions. If we take seriously the sorts of harms that Miranda Fricker (2007) and others have convincingly argued can arise from testimonial injustices and other epistemic oppressions (Dotson 2011), it becomes clear how harmful it was for Pean qua knower to have his claims about his mental state repeatedly brushed off, dismissed, and ignored. One can be invalidated in many senses, but calling what happened an epistemic microaggression pinpoints the distinctly epistemic dimension of the interaction, and underscores the specificity of the epistemic harms that resulted. Pean's very capacity and position as a knower were undermined. Being a knower is crucial to one's agency and personhood; it is essential to being human. It's in this sense that microaggressions did serious epistemic (among other types of) harm, rather than just invalidating him more generally, as Sue's account holds. We aren't questioning whether it's harmful to have one's thoughts, feelings, and experiential reality negated. Rather, our point is that our proposed account is better able than Sue's to highlight the precise epistemic dimension of harm.
A second case that helps to show how our account is better able to provide a precise analysis of the kind of harm suffered by victims of microaggressions than Sue's is Xeph Kalma's. Recall, she was deadnamed in the ER. Her birth name (that still appeared on her identification) was no longer a part of her identity, as she expressed numerous times to her medical team. Being repeatedly called by that name and simultaneously misgendered during her visit threatened her sense of self. As with Pean's case, if we stick to Sue's taxonomy of microaggressions, it's difficult to pinpoint the precise nature of harm suffered by Kalma. On Sue's account, deadnaming could either count as a microinvalidation insofar as the victim's personhood is invalidated by failing to recognize who she is, or possibly as a microassault, defined as an explicit "derogation characterized primarily by a verbal or nonverbal attack meant to hurt the intended victim through name-calling, avoidant behavior, or purposeful discriminatory [End Page 434] actions" (Sue et al. 2010, 274). To be deadnamed and misgendered was extremely harmful to her general well-being, as conveyed in her testimony above. However, neither of Sue's categories of microaggressions manages to capture the precise and enduring harm to Kalma that a self-identity microaggression and the resulting existential harm does; both seem to collapse all types of harm under one general category. Kalma describes being deadnamed as a constant reminder of terrible times in a person's life. The fact that her healthcare team continued to deadname her, even though she explicitly told them the name that she uses, is harmful to the core of her being and violates her sense of self. What Kalma described wanting (and what she felt her healthcare team failed to do) was to treat her "like a human being who is worthy of respect" (2017, 204). Using the language of self-identity microaggression and the resulting existential harm highlights that what occurred to Kalma had implications for her identity and sense of self in an enduring way. We're suggesting that an account that labels microaggressions on the basis of their harms is better able to capture what's morally wrong in the case—a conclusion that isn't as easily or readily reached when her experience is described using Sue's more general language of microassault or microinvalidation, which lumps all harms into a single category.
The language we use to describe microaggressions has consequences for the way we think about them—how severe they are, how much harm they inflict upon those on the receiving end, the precise nature of this harm, and thus, how important they are for us to confront. For this reason, it's preferable to describe microaggressions in ways that are most accurately able to capture what is morally salient—the particular, severe, and enduring harms that result from microaggressive acts. While Sue's taxonomy conveys the idea that harms are done to victims, it doesn't specify the specific kinds of harm. However, when we start from the position of the harms experienced by victims, as opposed to the actions of the microaggressors, we can better understand the significance of microaggressions and why they're thus important for healthcare providers and others to avoid.
Presently, we aren't launching a full argument in favor of our taxonomy of microaggressions, nor are we completely rejecting Sue's account. Rather, as a preliminary foray into this issue, we hope that by showing how our account is better suited to capture the precise kinds of harm that result from various types of microaggressions, we might motivate readers to think anew about the starting point that's traditionally been taken, and continues to be taken, to discuss and understand the phenomenon and to [End Page 435] consider how microaggressions might be re-conceptualized if we take on a different standpoint, namely, that of victims and the enduring harms they experience. Doing so (in addition to doing more service to the perspective of those harmed by microaggressions) might also foster a change in how society thinks and talks about microaggressions, insofar as it illuminates how genuinely harmful they are for victims, a question which still receives plenty of debate and skepticism.27 Intervening in microaggressions through awareness, education, and training might be more likely and less contentious once we make such a shift in the cultural mindset towards a recognition of the ways in which they really do impact people's lives in enduring, harmful ways.
Before concluding, we'd like to acknowledge a possible objection to our proposal. One might argue that Sue's account of microaggressions is sufficiently victim-centered, insofar as his primary aim in theorizing microaggressions is to bring to light a phenomenon that affects structurally oppressed people. However, we see Sue's account as treating the harms experienced as secondary, insofar as his account doesn't center on those experiences, but rather focuses on and is guided by what the actor/ microaggressor is doing to that oppressed person. That is, his account takes as its point of departure the agency of the microaggressor, as opposed to theorizing from the position of those harmed. In so doing, Sue's account is unable to make much headway on differentiating the unique harms that may result from the types of acts he identifies—something that's required of any account of microaggressions. He spends significant time making the case for the different categories of microaggressive acts, but gives little attention to the diversity of harms that might follow from them.
This is evident in much of the literature that utilizes Sue's taxonomy to research the negative impact of microaggressions. This empirical research uses Sue's three categories to examine how microaggressions generally cause harm, mostly without distinguishing between distinct harms that result from the different types of microaggressions. The conclusions are thus of the form: microaggressions contribute to x, y, and z harms, without attention to whether or not the distinct types of microaggressions cause harm differently, or cause different harms altogether. For example, Hunn et. al 2015, Berk 2017, and Munro 2017 rely upon Sue's tripartite distinction of microaggressions, but when they move to discussions of harms, all harms caused by microaggressions are lumped together into a single category. Though we aren't contesting that microaggressions cause harm, we believe that an account that calls for a more nuanced [End Page 436] distinction between different types of harms caused by different types of microaggressions is superior insofar as it better maps on to and describes the phenomena under consideration. In other words, significant nuance is lost when we fail to consider the unique harms of particular types of microaggressions. Thus, as research and discussion on microaggressions continues, it's beneficial to consider adopting an account which can illuminate some of this nuance.
In this paper we've discussed the dangerous consequences of microaggressions within the context of clinical medicine. We've proposed a possible, even if only tentative, alternative classification of microaggressions within this context that takes the harms experienced by patients as its point of departure. In doing so, we've articulated three types of microaggressions—epistemic, emotional, and self-identity microaggressions—which result in harms that are epistemic, emotional, and existential respectively. We've illustrated each within a medical context by providing examples drawn from patients' firsthand experiences. By centering the experiences of victims of microaggressions themselves, we hope to have shown how harmful microaggressions in medical contexts can be, and thus, to have provided compelling reasons why healthcare providers ought to know about them and actively work to avoid committing them. Our hope is that future extensions of this work can (1) develop the new classification of microaggressions that we've offered here, thus shifting the terms of the debate to focus on the perspectives of victims as opposed to aggressors and (2) use this revised classification and the related harms to begin developing practical tools that can be used to aid healthcare providers in recognizing and avoiding the microaggressive acts that result in these types of harms in their clinical practice. [End Page 437]
Lauren Freeman, PhD, is an Associate Professor in the Department of Philosophy at the University of Louisville. She is also an affiliated faculty member in Women's and Gender Studies, a core member of the MA in Bioethics and Medical Humanities, a collaborator with University of Louisville's School of Medicine's eQuality Project, and a former collaborator with the Center for Mental Health Disparities (in the Department of Psychology). She does research in the areas of feminist bioethics, philosophy of medicine, feminist philosophy, phenomenology, philosophy of emotion, and philosophical pedagogy.
Heather Stewart is a PhD student at the University of Western Ontario. Before arriving in Ontario, she completed her MA in Philosophy and graduate certificate in Women and Gender Studies at the University of Colorado Boulder. Heather does research in feminist bioethics and social and political philosophy, with particular focus on improving health care delivery to queer and trans communities. She is currently co-authoring a book on microaggressions with Dr. Lauren Freeman.
1. "Imposter syndrome" describes high-achieving individuals who are unable to internalize their accomplishments or to believe that they are in fact successful and who live with a persistent fear of being exposed as a "fraud."
2. For instance, in the scholarly literature, Sue 2010, Nadal et al. 2011, and Nadal 2013 have introduced and developed the phenomenon. Lilienfeld 2017a has questioned the science behind how microaggressions have been studied and, quite radically, has called for a moratorium on any workshops that attempt to help prevent the occurrences of microaggressions until the research program has been validated. In both scholarly and popular venues, Haidt (2017, 2016 respectively, and also 2018) has questioned the seriousness of microaggressions and, following Campbell and Manning 2014, has argued that microaggressions promote a culture of victimhood (thereby dismissing the extent to which they in fact cause real harm). Ong et al. 2017 and Sue 2017 have defended microaggressions against charges leveled against them in Lilienfeld 2017a, including Haidt's. Other defenders of microaggressions include Friedlaender 2018, Huynh 2012, Kaskan & Ho 2014, Joshi Wynn et al. 2015, Decuir-Gunby and Gunby 2016, Isom 2016, and Pitcher 2017. For accounts of microaggressions that are specifically focused on clinical counseling and other clinical psychology contexts, see Sue et al. 2007, Constantine 2007, Sue et al. 2008, Owen and Rodolfa 2010, Nadal et al. 2012, Shelton and Delgado-Romero 2013, DeLapp and Williams 2014, and Hook et al. 2016. Also see Rini (forthcoming) for the only sustained discussion of microaggressions by a philosopher.
Within popular media, a large part of the microaggression debate has focused on microaggressions on college campuses (see, for example, McWhorter 2014, Vega 2014, and Friedersdorf 2015) with many suggesting that claims of microaggressions are vastly overblown (e.g., Lilienfeld 2017b, Lilienfeld 2017c, and Mac Donald 2017). Lukianoff and Haidt (2015) have suggested that talk of microaggressions corrodes public discourse and encourages accusations and counter-accusations rather than critical thinking. Many have responded to such attacks on microaggressions, including Ho 2015, Joseph 2015, Riedel 2016, Rini 2015, Runyowa 2015, and Weiss 2016.
3. Since there's been very little substantive work on microaggressions within clinical medicine, we see this paper as making an important contribution. Some basic treatments of the topic can be found in Bleich 2015, Montenegro 2016, and May 2017. These articles focus on microaggressions within the profession of medicine, specifically, between higher and lower ranks of physicians, physicians and medical students, and between physicians and nurse practitioners. None of them discusses microaggressions that occur between physicians and patients. Hall and Fields 2012 discuss racial microaggressions between nurses and patients, though they focus on counseling relationships. We're adding to the literature by broadening discussions of microaggressions in medical settings to include microaggressions that focus on harms to patients. Walls et al. 2015 is an exception insofar as it considers microaggressions experienced by patients; however, it focuses on the narrow patient group of American Indians with type 2 diabetes. Another exception is Smith-Oka 2015, which examines the effects of microaggressions in another narrowly defined population group of obstetric patients in public hospitals in Mexico.
4. We're grateful to the following individuals for their comments on and discussions about drafts of this paper: Andreas Elpidorou, Stephen Hanson, Avery Kolers, Monnica Williams, and especially to two anonymous reviewers for their meticulous readings of two drafts of this paper. Additionally, we're grateful to audiences at the Southern Society of Philosophy and Psychology (2016), the Kentucky Philosophical Association (2016), FEMMS 6 (2016), the Eastern Division meeting of the American Philosophical Association (2017); as well as to students in Lauren's 2016 and 2017 Gender, Race, Culture and Health Care classes at University of Louisville, and to Alison Jaggar's 2017 Feminist Methodologies seminar at the University of Colorado Boulder. Finally, we're appreciative of the Commonwealth Center for Humanities and Society (John Gibson in particular) and the Cooperative Consortium for Transdisciplinary Social Justice Research, both at University of Louisville, for their generous support of this project. Lauren Freeman is also grateful to Kristen Connors for being a condition for the possibility of getting to work on this paper as much as she did.
5. We use "existential harms" to refer, broadly, to the various harms to self-identity and one's sense of self that result from self-identity microaggressions.
8. Lilienfeld (2017a) problematizes the conceptualization of microaggressions and the associated research program, arguing that the concept of microaggressions is incoherent, insofar as "aggression" implies intentionality (147). Though not written as a response to this article, Brennan (2016) provides a compelling argument to the contrary. Contra Lilienfeld, and in line with Brennan, we contend that microaggressions are problematic and harmful, irrespective of the intentions of the aggressor, since victims can be harmed even if it wasn't the intention of the perpetrator. Also see Friedlaender (2018).
9. Our account differs from Carel and Kidd's insofar as our account takes an intersectional approach to distinguish different levels of marginalization within the group "patient," whereas theirs doesn't.
10. Fricker 2007 provides a general account of epistemic injustices and resulting harms. She articulates two types of epistemic injustice: testimonial injustice and hermeneutical injustice. Since the publication of her book, there's been a growing philosophical literature on the topic. Dotson 2011, 2012 and Medina 2013 challenge and expand Fricker's account within the context of race. Carel and Kidd 2014 discuss epistemic injustices within medical contexts. Carel and Györffy 2014 consider how children are particularly vulnerable to epistemic injustices in healthcare settings. Freeman 2014 discusses epistemic injustice in pregnancy. Sanati and Michalis Kyratsous 2015 discuss epistemic injustices in psychiatry. Also see Kidd, Medina, Pohlhaus (eds.) 2017.
11. Freeman and Stewart 2019 discuss the relationship between epistemic microaggressions and testimonial injustices.
15. Here we employ Fricker's distinctions of primary and secondary harms. By calling these harms "secondary," we aren't implying that they're less serious.
17. We'd like to thank Reviewer 2 for pushing us to clarify this point.
18. This paper doesn't discuss the practical steps that healthcare providers should take in order to avoid committing microaggressions but a follow-up paper will.
19. See Carel 2014, chapter 1 for an account of how the microaggression of the physician who diagnosed her illness had lasting and harmful emotional effects on her. Though Carel doesn't use the language of microaggressions, we take her experience as described to be a clear example of them.
20. Though our focus here is emotional harms of microaggressions, we'd be remiss were we not to say something about the epistemic dimension of the harm. For physicians to consistently have discredited, undermined, and ignored Rachel's claims to and experiences of pain (based on gender stereotypes) is an example of an epistemic microaggression since they failed to give uptake to her claims about her body. Instead, they relied on their own (incorrect) assumptions of the problem and privileged their third-personal knowledge.
22. Freeman and Stewart forthcoming 2019 provide an account of the differences between emotional microaggressions and gaslighting.
23. Thanks to Reviewer 2 for pushing us to clarify this point.
26. Patient-centered care is a model built upon the active collaboration and shared decision-making between patients, families, and providers. In patient-centered care, one's specific health needs and desired health outcomes are the driving forces behind all healthcare decisions. Patients are partners with their healthcare providers, and providers treat patients holistically from a clinical, emotional, mental, spiritual, social, and financial perspective (NEJM 2017).
27. See note 2.