Microaggressions are “everyday derogations, slights, and invalidations that are often delivered to people of minority or marginalized backgrounds” (Lui & Quezada, 2019). Daily microaggressions such as heterosexism (thinking heterosexual people are the norm and assuming everyone is heterosexual), assuming gender pronouns, or placing heterosexual norms about sexuality or relationships on an LGBTQIA+ person can have a larger impact than overt forms of discrimination (Tulshyan, 2022). LGBTQIA+ community members experience microaggressions daily. One example is a heterosexual person cringing or flinching when they see a same-sex couple showing public displays of affection. This uncomfortable reaction reinforces the idea that LGBTQIA+ couples are not accepted and are not safe to be who they are without judgment.

Microaggressions and Their Impact

LGBTQIA+ youth who experience microaggressions are at a high risk of victimization (Ching et al., 2022). In addition, LGBTQIA+ youth experiencing microaggressions are likely to feel chronic hypervigilance as they feel ambiguous acts of aggression from various settings (Sterzing, & Gartner, 2018). Some examples of  microaggressions include:  

1.  use of heterosexist/transphobic terminology
2. endorsement of heteronormativity/gender binaries
3. assumption of sexual pathology, and
4. discomfort or disapproval of LGBTQ identities or experiences” (Nadal, 2018). 

These examples help us to understand the breadth of microaggressions for LGBTQIA+ people. Some commonly reported mental health symptoms after repeated exposure to microaggressions include depression, low self-esteem, and for some, may present as trauma (Nadal, 2018).

Impact of Microaggressions in the Clinical Setting

In a clinical setting, if a clinician avoids talking about or minimizes a client’s gender identity or sexuality–such as by using words like “choice” or “lifestyle”–can send the same extraordinarily invalidating message.  A therapist must be aware of the words that they use with LGBTQIA+ clients, especially when working with youth. Youth in the LGBTQIA+ community may have a high rate of dysphoria around body image due to increased comparison of their development to their peers, as well as their own exploration of sexuality and gender identity, which can complicate word choice from therapists (Taylor & Nepp, 2019). Therapists’ language around body image carries a higher risk of coming across as a microaggression to their client (Sterzing & Gartner, 2018). For example, comments about a client’s body or appearance such as “you’ve lost weight!” may harm a client’s developing self-image, even if the therapist has good intentions. Clinicians can also unknowingly make microaggressions towards non-binary clients through misuse of pronouns or misgendering them based on their physical appearance. 

Addressing Microaggressions in Clinical Settings

Beneficence is the idea of doing the most good with the least amount of harm, a common ethical principle among mental health providers (American Psychological Association, 2017). As a clinician working with LGBTQIA+ community members, you are at risk of enacting microaggressions towards the client you are trying to help. Therapists are part of a complex power dynamic with their clients, and to promote beneficence, they should be aware of this risk. 

One evidence-based method that can help address microaggressions  within the therapeutic relationship is called NAME (Byers et al., 2019), which stands for:

• Notice
• Acknowledge
• Make space and
• Enlist the group 

Providing Psychoeducation 

A clinician can teach their client to utilize this method as a way of addressing microaggressions in their life outside of the therapy room. First, the clinician would utilize mindfulness techniques to help the client become aware of the microaggressions. Then they would teach emotion regulation skills, as well as build autonomy and self-confidence through becoming proficient with NAME. Once the client is feeling comfortable with recognizing microaggressions in their daily life, they can verbally acknowledge the microaggression. Once acknowledged, the client can make space, ignoring any attempt the aggressor might have at minimizing the microaggression, and creating a conversation about what occurred. Finally, the client can enlist people around them to join the conversation, to acknowledge and support the recipient of the microaggression. 

This method was originally developed for students and teachers to call out microaggressions in classrooms (Byers et al., 2019). Researchers found evidence that calling out microaggressions in class helped improve the environment for members of minority groups (Byers et al., 2019). In the same way, NAME can also be a helpful practice to teach LGBTQIA+ youth clients as a skill to use outside of therapy sessions as well. By using NAME, you can promote beneficence by empowering your client to use a method that helps a client call out microaggressions and calls for community support for the client as well. 

Case Example

I provided services to a 15-year-old transmale utilizing he/him pronouns in an in-home therapy setting. This client had a significant history of victimization by peers as well as family rejection. The client also had a significant trauma history of sexual and emotional abuse. The client spoke at length about how he wanted to feel okay, but wherever he was, he felt unaccepted. Whether it was in class, where he would overhear he was being called numerous slurs by his peers, or at home where his parent misgendered him constantly, the client felt rejected by others. 

The client emphasized the impact of microaggressions on this feeling of not belonging. At first, he was not aware of the word microaggressions, but described experiences that fit this category, such as peers’ uncomfortable physical reactions to how he dressed or presented his gender. This client consistently faced ostracization from social groups because of his sexual orientation and gender identity which was felt through the constancy of microaggressions he was experiencing. He struggled to escape the impact of microaggressions because they were everywhere across social settings, from the community at the park across the street from his home, at school, and within his peer groups. This client presented with a deep depressive state, as well as self-harm due to feeling unaccepted by others. He also reported feeling unsupported by his parent, who frequently commented how he should be sent to residential treatment because it would be better than being home. His parent would tell him his gender identity was a “phase” or misgender him when talking to healthcare providers by telling them it was a phase as well.  

Therapeutic Response 

Focus on Affect

In working therapeutically with this client, I found it helpful to utilize a grief-focused Acceptance and Commitment Therapy (ACT) approach. This approach was effective to help the client understand himself and commit to the goal of improving his depressive symptoms. As a clinician, my approach was dual-fold: first, I helped the client accept that though they are painful, he will experience microaggressions throughout his lifetime. The power microaggressions have lies in making the victim feel insignificant and ostracized from others. There is an inherent sadness and loss in accepting their inevitability, and it was important for the client to feel and process these emotions. By accepting this lack of control, the client was able to move from anger and sadness towards a new emotional response to microaggressions. By having the client focus on accepting his lack of  control over others’ comments, he was able to shed the beliefs that the world hated him for his identity and that he was insignificant. In turn, this improved the client’s self-esteem. 

Empowerment

Secondly, I sought to empower the client to respond to microaggressions. I started by acknowledging that the client was accepted in the therapeutic setting, and moved towards identifying people who accept him in other domains of his life. I provided psychoeducation about chosen family and queer community to encourage the client to find a community of people like him. Together, we processed the impact of the microaggressions he had experienced in his close relationships, and identified how they are an expression of systemic hatred and ignorance rather than simply an individual slight. By offering these ideas to the client, the power balance changed from him feeling consumed by microaggressions to growing more self-confident and prepared to respond. The client felt a sense of autonomy which provided a space to engage in more advanced types of therapy, such as a cognitive restructuring approach from Trauma-Focused Cognitive Behavioral Therapy to challenge the intense cognitive distortions that had developed over time.

Attuning to Body Language

 In addition, I have found that the Gestalt approach of calling attention to the client’s body language, which is theorized to come from not feeling seen, heard, or understood, is effective in working with LGBTQIA+ youth (Bergheim, 2019). The theory is that people hold more information in themselves than they express verbally. For example, a clinician identifying a client will always use their middle finger on their right hand to tap their knee when they minimize a feeling may choose to share this observation with the client. This approach signals to the client that there is more to the story as the therapist elicits the feeling from the client and  helps them to feel seen, which subsequently builds rapport (Bergheim, 2019). This comes from what is called Tacit knowledge, “intuitive knowledge,” or “silent stories” in Gestalt work (Bergheim, 2019).  

Conclusion on Microaggressions

Microaggressions are constant. They are a product of a system of oppression that favors a majority culture (Fattoracci et al., 2021). Because of their pervasiveness, it is important to take a comprehensive approach to addressing them.
First, therapists must provide validation and acceptance of their minority clients. This is vital, as microaggressions can create or worsen depressive symptoms like low self-esteem and social isolation. Second, therapists should promote not just empowerment of their clients, but also education and advocacy on behalf of LGBTQIA+ people and communities to normalize gender and sexual minorities. Empowering our clients helps them to gain self-esteem and reduce depressive symptoms. The initial sadness of stating there is no control over microaggressions is overcome by the empowerment of acceptance of their situation. Acceptance can allow barriers such as anger or sadness to fall away as  the client steps towards empowerment, perhaps even calling out microaggressions and self-advocating. 

As clinicians we must address systemic oppression, including microaggressions at the interpersonal level. It is widely believed that by improving public knowledge, we can expect a reduction in global microaggressions towards the LGBTQIA+ community, making it an even more important priority in the therapy room (Byers et al., 2019; Fattoracci et al., 2021; Nadal, 2018; Sterzing & Gartner, 2018).

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References

American Psychological Association. (2017). Ethical principles of psychologists and code of conduct. American Psychological Association. Retrieved November 2022, from https://www.apa.org/ethics/code 

Bergheim, B. (2019). Accessing tacit knowledge: A street-level method. Journal of Social Work Practice, 35(1), 51–61. https://doi.org/10.1080/02650533.2019.1700491 

Byers, D. S., McInroy, L. B., Craig, S. L., Slates, S., & Kattari, S. K. (2019). Naming and addressing homophobic and transphobic microaggressions in Social Work Classrooms. Journal of Social Work Education, 56(3), 484–495. https://doi.org/10.1080/10437797.2019.1656688  

Ching, T. H., Finkelstein-Fox, L., Lee, S. Y., & Watson, R. J. (2022). Effects of sexual and gender minority stress on depressive symptoms among adolescents of color in the United States. Cultural Diversity and Ethnic Minority Psychology. https://doi.org/10.1037/cdp0000562 

Fattoracci, E. S., Revels-Macalinao, M., & Huynh, Q.-L. (2021). Greater than the sum of racism and heterosexism: Intersectional microaggressions toward racial/ethnic and sexual minority group members. Cultural Diversity and Ethnic Minority Psychology, 27(2), 176–188. https://doi.org/10.1037/cdp0000329 

Lui, P., & Quezada, L. (2019). Microaggressions: What they are, and how they are associated with adjustment outcomes. American Psychological Association. Retrieved October 2022, from https://www.apa.org/pubs/highlights/spotlight/issue-133 

Nadal, K. L. (2018). A decade of microaggression research and LGBTQ communities: An introduction to the special issue. Journal of Homosexuality, 66(10), 1309–1316. https://doi.org/10.1080/00918369.2018.1539582 

Sterzing, P. R., & Gartner, R. E. (2018). LGBTQ microaggressions and microaffirmations in families: Scale Development and Validation Study. Journal of Homosexuality, 67(5), 600–619. https://doi.org/10.1080/00918369.2018.1553350 

Taylor, A. B., & Neppl, T. K. (2019). Intimate partner psychological violence among GLBTQ college students: The role of Harsh Parenting, interparental conflict, and Microaggressions. Journal of GLBT Family Studies, 16(1), 47–65. https://doi.org/10.1080/1550428x.2019.1577200 

Tulshyan, R. (2022, March 8). We Need to Retire the Term “Microaggressions.” Harvard Business Review.