June is Pride month, and a perfect time to think about the power of our everyday language.
If you’ve read around this site or heard my podcast series, you know I’m one of the people interested in how health disparities are related to words, phrases and terms used around issues of health.
So this is about LGBTQ health disparities, their connections to the way language is used in health settings, and what you can do to improve the relationship between the two.
Disparities in LGBTQ health
HealthyPeople2020 summarizes research which suggests that “LGBT individuals face health disparities linked to societal stigma, discrimination, and denial of their civil and human rights.” They link to studies behind these health disparities, which include:
- LGBT youth are 2 to 3 times more likely to attempt suicide.
- Elderly LGBT individuals face additional barriers to health because of isolation and a lack of social services and culturally competent providers.
- Lesbians are less likely to get preventive services for cancer.
- Gay men are at higher risk of HIV and other STDs, especially among communities of color.
- LGBT populations have the highest rates of tobacco, alcohol and other drug use.
- Transgender individuals have a high prevalence of HIV/STDs, victimization, mental health issues, and suicide and are less likely to have health insurance than heterosexual or LGB individuals.
Health disparities are due to many factors that are man-made.
You may already be aware of the documented links between disparities in people’s receipt of health care and health care professionals’ implicit bias. As an educator, I see parallels between these findings and similar findings in the education sector. There, too, is a body of research showing that teachers can unintentionally treat students differently based on race, class, gender, sexual orientation, language background, and more.
This is distressing, considering that most of us in helping professions genuinely seek to serve everyone equally. So I’m digging into the research base, and my 20+ years of experience with students and faculty, for what I’ll share here. Specifically, I’m offering something that’s a way to think about, and potentially to work with, everyday language.
Ordinary words in clinical interactions
I’m particularly interested in what language, literacy, and power have to do with each other in (and beyond) the health sector. As health professionals, your language, in part, constitutes care.
What does this have to do with disparities?
There are subtle ways our everyday language can unintentionally disadvantage certain social or cultural groups. Words and silences in clinical interactions can erode equity, even (and perhaps especially) when we don’t notice them.
As NPR reports, nearly 1 in 5 LGBTQ adults has avoided seeking medical care for fear of discrimination.
Looking closely at our language is one concrete way to address unconscious bias, and the health disparities attached to them.
More than 30 years ago, law scholar Charles R. Lawrence III wrote:
Another manifestation of unconscious racism is akin to the slip of the tongue. One might call it a slip of the mind. While one says what one intends, one fails to grasp the racist implications of one’s benignly motivated words or behavior.”
It’s unsettling to realize we may be offending people accidentally. And, as this article points out, it can be jarring for health professionals to think about unintentionally contributing to health disparities through ordinary clinical interactions. That is where I join others who suggest microaggression research can be a useful resource.
Microaggression research challenges bias and inequity through drawing attention to, and working with, everyday language.
What are microaggressions?
In 2007, Sue et al’s groundbreaking study defined microaggressions as
“brief and commonplace daily verbal, behavioral, and environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative slights and insults” to members of marginalized groups. They are communicated through words and actions.
I was in graduate school at the time this study was published, and a member of the research team came to my university to discuss it. It made such a powerful impression on me that I still have the paper handout from that talk.
Sue et al’s article focused on racial microagressions. Since then, microaggression taxonomies have been developed focusing on gender, LGBTQ people, and other social groups.
Microaggressions do real harm
Here is a brief sample of recent research into LGBTQ harm specifically from microaggressions:
- sexual minority clients in psychotherapy may feel coerced into receiving treatment that they may not have initially sought or agreed to [Kia, H., Ross MacKinnon, K., & Legge, M. M. (2016)]
- school-based experiences of microaggressions that target a student’s sexual or gender minority identity are associated with psychological distress and attempted suicide [Gartner, E., & Sterzing, P. R. (2018)]
- sexual orientation microaggressions may be associated with risky alcohol behaviors that may be stress related [Bostwick, W., & Hequembourg, A. (2014)]
- LGBT older adults may avoid seeking care when needed because of micgroaggresive experiences (Foglia, M. B., & Fredriksen-Goldsen, K. I. (2014)]
Importantly, it’s not realistic to assume LGBTQ people are experiencing only one form of discrimination. Many of the studies I refer to here are informed by intersectionality.
Examples of LGBTQ microaggressions
Microaggression researchers often collect statements made or heard by study participants, along with contextualizing data, and identify patterns across these occurrences. It is common to read of ‘themes’ that emerge in the data analysis, along with examples from data.
I offer here a chart I’ve adapted from findings in Nadal, Whitman, Davis, Erqzo & Davidoff’s 2016 Microaggressions Toward Lesbian, Gay, Bisexual, Transgender, Queer, and Genderqueer People: A Review of the Literature.
|Use of heterosexist or transphobic terminology||Saying “No homo!,” which connotes that one does not want to be perceived as gay|
|Endorsement of heteronormative cultural/behaviors||Expecting children to adhere to traditional gender norms in terms of dress|
|Assumption of universal LGBTQ experience||Stereotyping all gay men as being promiscuous or all lesbians as being “butch”|
|Exoticization||Assuming a bisexual woman would be interested in having sex with a heterosexual couple|
|Discomfort/disapproval of the LGBTQ experience||Condemning LGBTQ people (e.g., telling an LGBTQ person that he or she is “going to hell”; looks of uneasiness when engaging in public displays of affection|
|Denial of reality of heterosexism/transphobia||When a transgender woman tells her friend that she experienced a microaggression and her friend replies with “It’s all in your head!” Or “You’re being too sensitive!”|
|Assumption of sexual pathology/abnormality||Supposing that LGBTQ people are living with human immunodeficiency virus [HIV] or are sexual predators or child molesters|
|Denial of individual heterosexism/transphobia||Someone becoming defensive when a lesbian challenges him or her on sexist or heterosexist behavior|
Addressing Implicit Bias Audiobook Bundle
This bundle of audiobook, eBook, and supplementary materials will help you address unconscious or implicit bias in your language. No matter your specialization or patient population. You get practical, culturally and linguistically relevant advice and research-based tools, in an unfussy, conversational format.
Why notice microaggressions? In order to:
- develop our understandings of our own language use
- begin to consider patterns of language use within and across our institutions
- interrogate, individually and collectively, larger social structures that contribute to discriminatory language use and inequities
That is, there is a good side here. As I’ve said before:
Since language is powerful enough to contribute to health disparities, I suggest it is powerful enough to reduce them.”
Kia, Ross MacKinnon & Legge underscore the potential for positive change through a shift in language use in their “Not a Real Family”: Microaggressions Directed toward LGBTQ Families.
“In much of our analysis, we have prominently foregrounded the use of language or discourse at the interpersonal level, both as a vehicle for perpetuating hypervisibility or silence, and as the very catalyst for change and resistance.”
What you can do
Remember, one-size-fits-all solutions are seductive–but misleading–when it comes to human communication. We don’t get it right, or arrive, or know it all. It’s a process.
Don’t put pressure on yourself to somehow have it all figured out about a group. Try taking an attitude of curiosity when it comes to communicating across social and cultural differences.
Shifting the terms and phrases you use during clinical encounters makes a difference. As van Ryn & Fu pointed out more than 15 years ago, “In this way, providers can influence help seekers’ expectations for the future, the degree to which they expect to obtain the resources and help they need, and their expectations for improvements in their situations or conditions, which in turn may account for some of the disparities observed in outcomes and health status.”
Involve patients and patient representatives in identifying their preferred terminology.
I’ve written before about asking respectful questions, such as “What would you consider a normal expressions of affection/attention/love?” [This question was inspired by an excellent conference presentation I saw from D’vorah Rose, co-editor of Struggling in Good Faith: LGBTQI Inclusion from 13 American Religious Perspectives]
I join my voice with those who, like Dovido & Fiske, necessarily connect individual level efforts to systems-level thinking. In “Under the Radar: How Unexamined Biases in Decision-Making Processes in Clinical Interactions Can Contribute to Health Care Disparities,” they point out that “Interventions are most likely to be effective when they occur at multiple levels” and assert that “systematically collecting data that could implicate the operation of subtle, distinct biases is critical for addressing the problem.”
Knowing there is not a way to remove bias from our language once and for all, I invite you to be a learner, listener, and an observer of language. If you’d like more support in this process, please contact me.