How to handle microaggressions and be aware of your own biases

Microaggressions are subtle discriminatory actions or statements made towards another person or group. Correcting them has always been a difficult task because the aggressors often do not know that what they are doing is wrong.

Ekene Enemchukwu, MD, MPH

The medical field is no stranger to microaggressions, and because they occur so frequently, it is important to continue to educate trainees and physicians on how to identify and handle them, and what their long-term effects can have on a person’s psyche. Ekene Enemchukwu, MD, MPH, dives into this topic further in a recent presentation given at the Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction 2022 Winter Meeting.¹

Enemchukwu is a pelvic reconstruction surgeon at Stanford Health Care, and an assistant professor of urology and obstetrics and gynecology at the Stanford University School of Medicine in California.

Please summarize the main points of your presentation.

This session was really meant to give people experiencing microaggressions some tools for mitigating the impact and the negative effects of microaggressions.

My take home points were the following:

1. Microaggressions are pervasive. Be prepared and be empowered.

2. You must protect yourself psychologically.

3. You must persevere. Do not allow them to damage you psychologically.

The “micro” in microaggressions, in my opinion, is a misnomer because they can have a significant impact on the individual, and ultimately, on your institution and on society as a whole because we all make up part of that team. There is data that shows that these microaggressions, actions or words that display bias or insensitivity towards a marginalized group, can cause some real psychological damage. Although they can be subtle and unintentional in some cases, they ultimately impact the entire team.

Individuals who are experiencing a microaggression must feel empowered. Feeling empowered means, at the moment of the aggression, pausing and stopping to take a minute and take inventory of your feelings do determine if you are feeling triggered. If you're feeling triggered at that point, it may not be a good time to respond to what just happened. There is a term for this, and it is the called the “90-second rule”. During this time, there is a fight or flight response, a biological instinct that floods us with adrenaline. It typically lasts about 90 seconds. As it pertains to microaggressions, these 90 seconds are not a good time to respond when you're in that fight or flight stage. You really want to stop, pause, take a moment, and collect yourself to see if it is a good time to respond.

At the end of the day, the goal is to protect yourself psychologically. Do not internalize what has been said and recognize your own value. You also want to decide, based on the relationship with the individual or the issue, whether you want to address it now, later, or never. But, again, you want to feel empowered and at peace with your decision, regardless of what your decision was.

It is important to seek support from your trusted peers and loved ones. These are the folks that will reinforce your value and help preserve your confidence. Allies are certainly important, but they may not always be present, so you need to have a contingency plan. On the other hand, if you're in the position where you're witnessing a microaggression, it's really important to speak up and say something on the behalf of that person experiencing it.

Depending on how egregious the incident was, or if there is a repeat offender ignoring your feedback, then the microaggressions could be intentional. In that case, you may want to keep a contemporaneous log of what's going on in these incidents, and potentially ask for assistance from HR, from your supervisor, your program director, or your chair.

When microaggressions occur, we often freeze and that is a natural instinct. And so, it's great to anticipate these events and think about how you want to respond ahead of time so that you're prepared when they do.

How you respond to microaggressions can vary based on the individual or the situation. There are different ways to respond. You can ask a clarifying question, you can acknowledge that the intent was not meant to be harmful, but the impact was harmful, or you can be direct and really state your discomfort. Some people like to use humor, but the goal here is to protect yourself psychologically, in that moment.

Finally, my last point was making sure that we are recognizing our own biases as well. Anyone can commit a microaggression. We have all been socialized by television, movies, social media, [and] society, to have biases and stereotypes. It is just like Pavlov's dogs. We see something, we hear something, we have this automatic reaction, and we make assumptions. And so, we certainly need to avoid being part of the problem and to make sure we speak up for others. It certainly takes practice, but we cannot give up.

Can you describe a time when you personally experienced a microaggression? How did you react and how did it make you feel?

Microaggressions are so pervasive, and worst of all, they are often invisible to the person committing them. For me, what I have learned in my experience is that it is really important to remember that anyone can commit microaggression. They can come from friends, family, colleagues, supervisors, subordinates, they can come from people of your same gender, race, ethnicity, social class, and many of us have experienced them, due to some element of our identity. But they are really dangerous because, most of the time, they're subtle and unintentional. Their impact is significant on our well-being, our confidence, our performance, and our integration into teams. Studies have shown that they can cause anxiety, depression, isolation, and post-traumatic stress disorder (PTSD). My personal response to microaggressions is dependent on the individual and my relationship with that person and the situation.

Having witnessed and experienced microaggressions, I've learned that they are one of the largest barriers to building inclusive teams and environments. They damage that sense of belonging. Imagine that one of the largest barriers to achieving greatness is something invisible to most people. That's really challenging. But it can be addressed by creating environments where we can learn from each other, so we can avoid the same subtle, often unintentional but harmful, destructive behaviors. We can achieve this by not being defensive, and by being open to learning and by checking our own biases. Also, [it is important to recognize] that threats to inclusion may not come directly from your own internal team or department. They may be come from outside. Having these discussions and having them frequently are help us recognize where these threats are coming from and help us address them. Without inclusive teams and environments, we all miss out on the unique talents of the individuals on our teams.

Lastly, in medicine, we are often seeking to create inclusive environments, not only for our colleagues, but we must create inclusive environments with strong senses of belonging for our trainees, our medical students and other learners who may not be in a position to speak up for themselves due to the power dynamics.

What advice would you give to fellow urologists or physicians on accepting and addressing their biases?

We can mitigate bias and the effects of microaggressions by being open to continuously learning. I've learned through leading our department's diversity, equity, and inclusion (DEI) efforts that one of the best ways to learn is by sharing our experiences. It helps us to identify our blind spots. Someone may hear something that they've said or done, or something that they've witnessed in the past, but may not have known that it was offensive. So, creating environments where we feel comfortable being vulnerable, and sharing those experiences, and where other folks are open to learning is important.

How has the world of medicine evolved in terms of DEI? What work is there still to do?

Most of all, I am very happy to see people take a genuine interest in improving diversity, equity and inclusion. I think there are still segments of society who think it's only about increasing numbers and representation of women, minorities, and other marginalized groups. Improving representation is a very important part of the mission, but DEI is also about creating systems where everyone currently here and those coming in the future thrive and are able to contribute in a meaningful way by making new discoveries, making things better, making things more efficient, and more productive for everyone’s benefit. Microaggressions, gaslighting, downplaying someone else's experience, or treating people differently based on their identity really works against this common goal. So, in urology, and really medicine as a whole, we are all striving to build that championship caliber team, and we're looking at recruiting diverse talent, but if we don't take the time to create the environments where all the team members can feel that they belong and can reach their full potential, then we as a whole may never reach our full potential in medicine.

Reference

1. Enemchukwu E. Microaggressions 2.0 – How to survive and thrive. Presented at: Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction 2022 Winter Meeting; San Diego, California. February 22-26, 2022.