How Sexual Microaggressions Have an Effect on Healthcare - Healthcare Guild

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Sexual Orientation Microaggressions: The Experience of Lesbian, Gay, Bisexual, and Queer Clients in Psychotherapy

Excerpt From: The Journal of Counseling Psychology: American Psychological Association, April 2011, Vol. 58, No. 2, pp. 210–221.  Authors: Kimber Shelton & Edward A. Delgado-Romero

The United States has become increasingly accepting of lesbian, gay, bisexual, and queer (LGBQ) individuals, and psychotherapy has undergone dramatic changes resulting in improved attitudes toward LGBQ clients, increased training opportunities on LGBQ issues, and a growth of LGBQ-focused psychotherapy literature. Although the trend is for greater affirmation, practitioners offer a mixed level of responsiveness to LGBQ clients and issues. On one hand, exemplary practices have been accounted for in which practitioners working with LGBQ clients expressed positive therapeutic experiences during assessment, intervention, and process (Garnets, Hancock, Cochran, Goodchilds, & Peplau, 1991); practitioners and practitioners in training exhibit greater interest in furthering their knowledge and insight pertaining to affirmative practices with LGBQ clients (Dillon et al., 2004), and there is an increase in the use of gay-affirmative approaches in therapy (Kilgore, Sideman, Amin, Baca, & Bohanske, 2005).

On the other hand, it remains the case that LGBQ clients continue to report considerable discrimination and hostility during the therapeutic process (Bowers, Plummer, & Minichiello, 2005; Greene, 2007) and that negative therapist variables such as bias and ignorance is present within many aspects of psychotherapy (i.e., intervention and assessment) (Garnets et al., 1991). LGBQ clients have detailed unhelpful therapy experiences during the course of therapy when their therapist exhibited unsupportive and dissatisfying reactions to their sexual orientation (Israel, Gorcheva, Walther, Sulzner, & Cohen, 2008). Overt forms of discriminatory practices, such as the practice of conversion or reparative therapies, have declined (Friedman & Lilling, 1996), yet considering the continued biased and unhelpful treatment experienced by LGBQ clients (Liddle, 1996), it is possible that overt forms of heterosexism have been replaced with more subtle forms of heterosexism (Bowers et al., 2005).

Subtle and covert forms of heterosexism within the therapy environment could potentially come across in the form of microaggressions. Microaggressions are communications of prejudice and discrimination expressed through seemingly meaningless and unharmful tactics. They may be delivered in the form of snubs, dismissive looks, gestures, and tones (Constantine, 2007; Constantine & Sue, 2007; Sue, Capodilupo, et al., 2007). The intention of a microaggression is to deliver a hidden denigrating, hostile, or negative message about a person or a group (Sue, Capodilupo, et al., 2007). For example, Sue and colleagues (Sue, Bucceri, Lin, Nadal, & Torino, 2007) note the use of “color-blindness” of White individuals making statements such as, “I don’t see color.” Overtly, this attitude appears to be a harmless statement, and potentially a possible admission of universal acceptance of others. However, the omission of seeing one’s race or ethnicity suggests an invisibility of ethnic minorities and denies the racial realties of ethnic minorities.

The subtle nature of a singular microaggression makes deciphering a microaggressive attack challenging. In fact, a microaggression is not identified by the occurrence of a singular event, but rather it is a product of the accumulation and regularity of small injustices that promote an environment of hostility and confusion to the target of the aggression (Solo ́rzano, Ceja, & Yosso, 2000; Sue, 2010a). Further complicating the identification of microaggressions is that they are often unconsciously communicated by well-meaning and kindhearted individuals, and can be easily ex- plained away through nonbiased and valid reasons (Sue, Capodilupo, et al., 2007). For instance, asking an Asian American individual, “Where are you from?” is seemingly safe and shows interest and curiosity; however, the effect of repeated exposure to such questions causes many U.S.-born Asian Americans to feel demeaned and like a “perpetual outsider” or foreigner (Sue,Bucceri, et al., 2007)...

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Sexual Orientation Microaggression Themes

Theme 1: Assumption that sexual orientation is the cause of all presenting issues

Theme 2: Avoidance and minimizing of sexual orientation

Theme 3: Attempts to over-identify with LGBQ clients

Theme 4: Making stereotypical assumptions about LGBQ clients

Theme 5: Expressions of heteronormative bias

Theme 6: Assumption that LGBQ individuals need psychotherapeutic treatment

Theme 7: Warnings about the dangers of identifying as LGBQ

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[Impact of Sexual Orientation Microaggressions]

The presence of sexual orientation microaggressions within the individual therapeutic environment had a negative impact on the therapeutic process. Confirmation of this finding came in the form of participants’ emotive reactions, attitudinal changes regarding therapy and therapists, and diminished help-seeking behaviors.

Affective consequences of sexual orientation microaggressions included clients feeling uncomfortable, confused, powerless, invisible, rejected, and forced or manipulated to comply with treatment. Participants felt invalidated, unaffirmed, frustrated, and angry when their sexual orientation and issues pertaining to sexuality were ignored, avoided, overrepresented in treatment, or pathologized. Clients felt as if their therapists could not understand their presenting problems or the sexual reality of LGBQ individuals. An example is noted in one participant’s comment, “And the person [therapist] just didn’t really listen to me. Like they didn’t believe that what I was saying was my actual experience.”

Clients’ active participation in the therapeutic process was com- promised when clients experienced sexual orientation microaggressions that left them feeling misunderstood and invalidated. Participants withheld information, failed to discuss their sexual orientation or issues relevant to sexual orientation, and felt the need to be deceptive to get their needs met. Fear of being seen as abnormal or different had a suppressive and muting affect on some participants’ disclosure of their sexual orientation to their therapists.

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Psychologists aspire to provide ethical and competent services to their clients with a special emphasis on attending to services provided to members of vulnerable populations. Over the last several decades, psychologists have been able to attend to the issues of overt prejudice and discrimination. However, as this study demonstrates, it is much more difficult to address the covert discrimination that may occur in the therapy relationship. When clients in this study were asked about their relationships with their therapists, they were able to relate stories that, when analyzed, revealed consistent themes related to the experience of microaggressions. In the section that follows, we focus on aspects of the results that merit further discussion.

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The power of sexual orientation microaggressions rest in their ability to stealthily debilitate the therapeutic environment for the purpose of continued indoctrination of systemic oppression. Correctly recognizing and labeling the confusion, resentment, and silence sexual orientation microaggressions leave in their wake is not an easy task for clients or therapists. However, acknowledgement of the existence of sexual orientation microaggressions and taking the risk to challenge microaggressions can set a therapeutic tone to foster enhanced conversations regarding power, privilege, and sexuality, likely improving the quality of the therapeutic relationship. As multiculturalism and qualitative research methodologies are designated as the fourth and fifth forces of psychology, psychology and counseling are primed to develop and use clinical interventions and research methodologies that disarm the power of sexual orientation microaggressions and truly encourage the growth and prosperity of LGBQ clients.

Avoiding Heterosexual Bias in Language

From:  American Psychologist , September 1991, Volume 46, Issue No. 9, 973-974
©1991 by the American Psychological Association, Inc.

Problems of Terminology

Problems occur in language concerning lesbians, gay men, and bisexual persons when the language is too vague or the concepts are poorly defined. There are two major problems of designation. Language may be ambiguous in reference, so that the reader is uncertain about its meaning or its inclusion and exclusion criteria; and the term homosexuality has been associated in the past with deviance, mental illness, and criminal behavior, and these negative stereotypes may be perpetuated by biased language.

  1. 1.The term sexual orientation is preferred to sexual preference for psychological writing and refers to sexual and affectional relationships of lesbian, gay, bisexual, and heterosexual people. The word preference suggests a degree of voluntary choice that is not necessarily reported by lesbians and gay men and that has not been demonstrated in psychological research.

    The terms lesbian sexual orientation, heterosexual sexual orientation, gay male sexual orientation, and bisexual sexual orientation are preferable to lesbianism, heterosexuality, homosexuality, and bisexuality. The former terms focus on people, and some of the latter terms have in the past been associated with pathology.

  2. 2.Lesbian and gay male are preferred to the word homosexual when used as an adjective referring to specific persons or groups, and the terms lesbians and gay men are preferred to homosexuals used as nouns when referring to specific persons or groups. The word homosexual has several problems of designation. First, it may perpetuate negative stereotypes because of its historical associations with pathology and criminal behavior. Second, it is ambiguous in reference because it is often assumed to refer exclusively to men and thus renders lesbians invisible. Third, it is often unclear.

    The terms gay male and lesbian refer primarily to identities and to the modern culture and communities that have developed among people who share those identities. They should be distinguished from sexual behavior. Some men and women have sex with others of their own gender but do not consider themselves to be gay or lesbian. In contrast, the terms heterosexual and bisexual currently are used to describe both identity and behavior.

    The terms gay as an adjective and gay persons as a noun have been used to refer to both males and females. However, these terms may be ambiguous in reference because readers who are used to the term lesbian and gay may assume that gay refers to men only. Thus, it is preferable to use gay or gay persons only when prior reference has specified the gender composition of this term.

    Terms such as gay male are preferable to homosexuality or male homosexuality, as are grammatical reconstructions (e.g., "his colleagues knew he was gay" rather than "his colleagues knew about his homosexuality"). The same is true for lesbian in place of female homosexual, female homosexuality, or lesbianism.

  3. 3.Same-gender sexual behavior, male-male sexual behavior, and female-female sexual behavior are appropriate terms for specific instances of same-gender sexual behavior that people engage in regardless of their sexual orientation (e.g., a married heterosexual man who once had a same-gender sexual encounter). Likewise, it is useful that women and men not be considered "opposites" (as in "opposite sex") to avoid polarization, and that heterosexual women and men not be viewed as opposite to lesbians and gay men. Thus, male-female behavior is preferred to the term opposite-sex behavior in referring to specific instances of other-gender sexual behavior that people engage in regardless of their sexual orientation.

    When referring to sexual behavior that cannot be described as heterosexual, gay, lesbian, or bisexual, special care needs to be taken. For example, descriptions of sexual behavior among animal species should be termed male-male sexual behavior or male-female sexual behavior rather than homosexual behavior or heterosexual behavior.

  4. 4.Bisexual women and men, bisexual persons, or bisexual as an adjective refer to people who relate sexually and affectionately to women and men. These terms are often omitted in discussions of sexual orientation and thus give the erroneous impression that all people relate exclusively to one gender. Omission of the term bisexual also contributes to the invisibility of bisexual women and men. Although it may seem cumbersome at first, it is clearest to use the term lesbians, gay men, and bisexual women or men when referring inclusively to members of these groups.

  5. 5.Heterosexual as an adjective is acceptable for people who have male-female affectional and sexual relationships and who do not engage in sexual relationships with people of the same gender.

  6. 6.The terms sex and gender are often used interchangeably. Nevertheless, the term sex is often confused with sexual behavior, and this is particularly troublesome when differentiating between sexual orientation and gender. For example, the phrase "it was sexual orientation, rather than gender, that accounted for most of the variance" is clearer than "it was sexual orientation, rather than sex, that accounted for most of the variance." In the latter phrase, sex may be misinterpreted as referring to sexual activity. It is generally more precise to use the term gender.

Goals for Reducing Heterosexual Bias in Language

  1. 1.Reducing heterosexual bias and increasing visibility of lesbians, gay men, and bisexual persons. Lesbians, gay men, and bisexual men and women often feel ignored by the general media, which take the heterosexual orientation of their readers for granted. Unless an author is referring specifically to heterosexual people, writing should be free of heterosexual bias. Ways to increase the visibility of lesbians, gay men, and bisexual persons include the following:

    a.  Using examples of lesbians, gay men, and bisexual persons when referring to activities (e.g., parenting, athletic ability) that are erroneously associated only with heterosexual people by many readers.

    b.  Referring to lesbians, gay men, and bisexual persons in situations other than sexual relationships. Historically, the term homosexuality has connoted sexual activity rather than a general way of relating and living.

    c.  Omitting discussion of marital status unless legal marital relationships are the subject of the writing. Marital status per se is not a good indicator of cohabitation (married couples may be separated, unmarried couples may live together), sexual activity, or sexual orientation (a person who is married may be in a gay or lesbian relationship with a partner). Furthermore, describing people as either married or single renders lesbians, gay men, and bisexual persons as well as heterosexual people in cohabiting relationships invisible.

    d.  Referring to sexual and intimate emotional partners with both male and female terms (e.g., "the adolescent males were asked about the age at which they first had a male or female sexual partner").

    e.  Using sexual terminology that is relevant to lesbians and gay men as well as bisexual and heterosexual people (e.g., "when did you first engage in sexual activity" rather than "when did you first have sexual intercourse").

    f.  Avoiding the assumption that pregnancy may result from sexual activity (e.g., "it is recommended that women attending the clinic who currently are engaging in sexual activity with men be given oral contraceptives," instead of "it is recommended that women who attend the clinic be given oral contraceptives").

  2. 2.Clarity of expression and avoidance of inaccurate stereotypes about lesbians, gay men, and bisexual persons. Stigmatizing or pathologizing language regarding gay men, lesbians, and bisexual persons should be avoided (e.g., "sexual deviate", "sexual invert"). Authors should take care that examples do not further stigmatize lesbians, gay men, or bisexual persons. An example such as "Psychologists need training in working with special populations such as lesbians, drug abusers, and alcoholics" is stigmatizing in that it lists a status designation (lesbians) with designations of people being treated.

  3. 3.Comparisons of lesbians or gay men with parallel groups. When comparing a group of gay men or lesbians to others, parallel terms have not always been used. For example, contrasting lesbians with "the general public" or "normal women" portrays lesbians as marginal to society. More appropriate comparison groups might be "heterosexual women," "heterosexual men and women," or "gay men and heterosexual women and men.'

Full article at:  American Psychological Association:

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