Race and gender play unique intersecting roles in the lives of Black women, making them especially vulnerable to gendered racial microaggressions.1 Microaggressions are defined as subtle verbal, behavioral, and environmental expressions of oppression toward the target group. These acts communicate hostile, derogatory, and negative slights; insults; or invalidations toward minorities and other stigmatized groups. The stigmatized groups can be classified based on race, gender, or a combination of the two.2 Microaggressions harm minority groups, such as Black women, by adversely affecting their psychologic well-being and physical health.2,3

Black women can experience racial microaggressions based solely on their race. Sue and colleagues classify racial microaggressions into three categories: microassaults (intentional harmful behavior), microinsults (insensitive, demeaning communications), and microinvalidations (exclusionary or nullifying communications).3 Across those categories, Sue and colleagues identified nine themes of microaggressions:

assumptions that people of color (POC) are not US citizens assumptions that POC are of lesser intelligence statements that elicit color blindness assumptions of criminal status denial of individual racism statements that assert the myth of meritocracy pathologizing cultural values/communication styles treatment of POC as second-class citizens environmental microaggressions.3

By examining a Black woman's experience through the lens of racial microaggressions, however, the effects of gender are not considered.4 Black women also can experience gender microaggressions, defined as subtle, seemingly benign statements or actions that convey sexism.2 Examples of gender microaggressions include stereotypical female role assumptions, overemphasis on physical appearance, and misattributing gender as a reason for accomplishing achievements.2,5 In a recent mixed-methods study, physicians who identified as female experienced significantly higher frequencies of gender microaggressions than male physicians (P < .001).5 This influenced job satisfaction, burnout, career perceptions, and behavior.5 The same problem arises when examining a Black woman's experience through the lens of gender microaggressions.2 The effects of her race are not considered.4

THEORETICAL FRAMEWORK

A more appropriate approach to specific microaggressions Black women face is examining how race and gender simultaneously play roles in their experiences. The intersectionality theory helps describe gendered racism by providing a framework to capture these unique experiences.4 Racial microaggressions and gender microaggressions can each contribute to a Black woman's distress, yet each concept alone does not consider the oppressive experiences specific to Black women.1 Racial microaggressions address minority issues of inequality; gender microaggressions define sexist experiences for all women.6,7 Although Black women can have racial experiences similar to Black men, they still can experience gender microaggression.6 At the same time, Black women experience gender microaggressions just as any woman, but Black women also have unique experiences that are specific to being Black and a woman.7 Viewing gendered racial microaggressions through the intersectionality lens allows for consideration of both a Black woman's race and gender.1 It captures these experiences by examining race and gender as one inseparable unit, in which the Black woman simultaneously experiences racism and sexism.4

The term gendered racial microaggressions captures the interconnectedness of a Black woman's gender and race. Gendered racial microaggressions are routine and subtle verbal, behavioral, and environmental slights that occur at the intersection of racism and sexism. The types of microaggressions that are unique to Black women are negative stereotypes (Jezebel, angry Black woman, mammy), being silenced and marginalized, and assumptions about beauty and style.2,8 These everyday occurrences have a cumulative negative effect on Black women by creating psychologic distress and forcing Black women to use coping strategies to deal with the stress.1

Gendered racial microaggressions are stressful because they can occur at any moment, in any setting, and often have a layer of ambiguity.1 Past literature has qualitatively and repeatedly shown the link between gendered racial microaggression and psychologic distress and its effect on Black women's education and career goals.2-4,8 Even as faculty members, Black women have been marginalized by their institutions because they often are required to have nonacademic diversity commitments that do not advance their careers or offer monetary compensation.9 They are chosen to mentor Black students and often are the face of the institution's diversity disclaimer without any sincere attempts by the institution to increase cultural competency.9,10 Being professionals does not shield Black women from gendered racial microaggressions. Their expertise is questioned, behaviors mislabeled as aggressive, and their presence remains invisible.10,11 The qualitative data from one study found that Black physicians who identified as female directly linked microaggressions to gender and race.5 These forms of oppression are particularly harmful to Black women when they are forming their personal and professional identities.12,13

Quantitative research on the stress associated with gendered racial microaggressions is limited. Furthermore, no research exists on the link between gendered racial microaggressions and distress among PAs who identify as Black women (for brevity, called Black women PAs throughout this article). According to the 2018 American Academy of Physician Associates (AAPA) Salary Report, 2% of PAs identify as Black women.14 Because PAs collaborate with healthcare teams to create better patient outcomes, optimal collaboration among Black women PAs, the team, and patients is crucial for patient care and clinician well-being.15

This study examined Black women PAs' perceptions of gendered racial microaggressions. The purpose of this mixed-methods study was to explore whether Black women PAs perceive that they experience gendered racial microaggressions and if this experience was correlated with psychologic distress.

METHODS

This study was granted exempt status by the A.T. Still University institutional review board. A combination of convenience, purposive, and snowball sampling methods was used to recruit participants from August to September 2019. All Black women PAs who were members of certain Facebook groups (Physician Assistant Moms, PA-C Professionals, and Physician Assistants of Color) were asked to participate in the study. Any member of those groups could share the survey link. Administrators of each Facebook group granted permission to post the survey link. This study was voluntary, and no compensation was offered.

To meet the inclusion criteria, participants had to self-identify as being Black, African American, or of African descent. They also had to identify as women. Lastly, they needed to be board-certified PAs with clinical experience.

Measurement

The Gendered Racial Microaggression Scale (GRMS) was created to empirically examine the gendered racial microaggressions Black women experience within the framework of the intersectionality theory.16 This scale is based on the premise that race and gender cannot be evaluated separately. Lewis and Neville analyzed the qualitative literature to construct a multidimensional scale that determines the frequency of and stress associated with gendered racial microaggressions against Black women.16

An anonymous online mixed-methods 27-item survey was used in this study. The participants answered demographic questions and were excluded from further sections of the survey if they did not meet the inclusion criteria. The qualitative portion solicited anecdotes of gendered racial microaggressions using an open-ended question asking the survey participants to elaborate on their experiences. The GRMS was used to quantitatively assess whether Black women PAs had experienced gendered racial microaggressions in clinical settings and if those experiences were associated with psychologic distress. The GRMS is a 6-point Likert scale composed of two main scales: frequency and stress appraisal. Both scales have four subscales: assumptions of beauty and sexual objectification, silenced and marginalized, strong Black woman, and angry Black woman.16

Quantitative analysis

Descriptive statistics were used to analyze the demographic data, to analyze the results of the GRMS and subscales, and to answer the research question about perceptions of Black women PAs. Composite scores were calculated, and valid percentages were used. The Shapiro-Wilk normality test was conducted on all scales, and an alpha level of 0.05 was used for all analyses. Chi-square analyses were used to answer whether a correlation exists between gendered racial microaggressions and psychologic distress.

Qualitative analysis

Three study team members (AGL, QSG, and ACG) reviewed the qualitative data. Two study team members QSG and ACG used inductive thematic analysis to analyze qualitative responses. AGL's role was to resolve any challenges that arose. Both coders (QSG and ACG) developed a preliminary codebook through immersion and identified themes individually. The coders then shared their preliminary themes and worked together to refine themes. This individual coding and group refining continued until all responses were grouped into 11 coded themes. Survey responses were assigned to multiple themes as seen fit by the coders.

Only 30 of the 34 participants elaborated on their experiences by answering the qualitative question. Team members coded all 30 responses, thoroughly discussing and critiquing discrepancies as needed. Each coder could raise questions if needed to determine themes for responses that were not straightforward. AGL reviewed coding across the team members when completed to identify and resolve any issues via group discussion. Overall, no substantial discrepancies existed at this stage.

IBM SPSS Statistics version 6 was used for statistical analysis. Descriptive statistics were used to analyze the data.

RESULTS

Sixty-six respondents started the survey. Some were excluded based on their answers to key questions (Table 1). Participants were excluded if they did not consent to the survey, if they did not select female as their sex, or if they did not identify as being Black, African American, or of African descent. One woman selected other for her race and further identified herself as being Black and White; therefore, she was included. Black women who were never eligible to practice as a PA (n = 5) or who never practiced clinically as a PA (n = 2) were excluded.

TABLE 1. - Survey respondent demographics (N = 66) Percentages may not sum to 100 because of rounding. Although the survey asked respondents' sex, it was meant for anyone who identified as a woman. n % Sex Male 8 12.1 Female 57 86.4 Missing 1 1.5 Race Black, African American, or of African descent 42 63.6 Asian 2 3 Hispanic 1 1.5 White 10 15.2 Other 1 1.5 Missing 1 1.5 Disqualified 9 13.6 Eligible to practice as a PA Yes 38 57.6 No 5 7.6 Disqualified 23 34.8 Ever practiced as a PA Yes 36 54.5 No 2 3 Disqualified 28 42.4

Thirty-six Black women PAs qualified for the study. Two did not complete any more demographic questions; therefore, valid percentages were used, and the sample size was reduced to 34 for the quantitative portion of the survey. Most participants (44.1%) were ages 35 to 44 years, had been working as PAs for fewer than 10 years (76.4%), lived along the East Coast of the United States (82.3%), and worked in urban locations (50%) (Table 2). Black women PAs worked in a variety of specialties: emergency medicine, internal medicine, and primary care were tied for the most common (11.8% each). Table 3 depicts the frequencies of gendered racial microaggressions and Table 4 depicts Black women PAs' stress levels associated with gendered racial microaggressions.

TABLE 2. - Characteristics of survey participants (N = 34) Percentages may not sum to 100 because of rounding. n % Age (years) 25-34 13 38.2 35-44 15 44.1 45-54 6 17.6 State of residence Florida 2 5.9 Georgia 8 23.5 Maryland 2 5.9 New Jersey 3 8.8 New York 3 8.8 North Carolina 5 14.7 Tennessee 1 2.9 Texas 4 11.8 Virginia 4 11.8 West Virginia 1 2.9 Wisconsin 1 2.9 Years of practice 0-5 13 38.2 6-10 13 38.2 11-15 4 11.8 16-20 3 8.8 21-25 1 2.9 Practice specialty Anesthesiology 1 2.9 Cardiology 1 2.9 Emergency medicine 4 11.8 Hospital medicine 1 2.9 Internal medicine 4 11.8 Obstetrics/gynecology 2 5.9 Orthopedics 3 8.8 Pediatrics 2 5.9 Primary care 4 11.8 Psychiatry 1 2.9 Surgery 1 2.9 Surgical subspecialty 1 2.9 Other 9 26.5 Type of community (practice location) Rural 4 11.8 Suburban 13 38.2 Urban 17 50
TABLE 3. - Respondents' perceived frequencies of gendered racial microaggressions Percentages may not sum to 100 because of rounding. Scales Never happened, n (%) Less than once a year, n (%) A few times a year, n (%) About once a month, n (%) A few times a month, n (%) Once a week or more, n (%) GRMS 3 (10.3) 15 (51.7) 7 (24.1) 3 (10.3) 1 (3.4) 0 Silenced and marginalized subscale 2 (7.4) 7 (25.9) 12 (44.4) 4 (14.8) 1 (3.7) 1 (3.7) Assumptions of beauty and sexual objectification subscale 8 (26.7) 14 (46.7) 5 (16.7) 3 (10) 0 0 Strong Black woman subscale 4 (13.3) 11 (36.7) 9 (30) 3 (10) 3 (10) 0 Angry Black woman subscale 7 (23.3) 11 (36.7) 8 (26.7) 0 3 (10) 1 (3.3)
TABLE 4. - Respondents' stress levels associated with gendered racial microaggressions Percentages may not sum to 100 because of rounding. Scales Never happened, n (%) Not stressful, n (%) Slightly stressful, n (%) Moderately stressful, n (%) Very stressful, n (%) Extremely stressful, n (%) GRMS 4 (13.8) 6 (20.7) 11 (37.9) 7 (24.1) 1 (3.4) 0 Silenced and marginalized subscale 2 (6.9) 3 (10.3) 5 (17.2) 7 (24.1) 7 (24.1) 5 (17.2) Assumptions of beauty and sexual objectification subscale 9 (30) 10 (33.3) 9 (30) 2 (6.7) 0 0 Strong Black woman subscale 6 (20) 15 (50) 6 (20) 2 (6.7) 1 (3.3) 0 Angry Black woman subscale 6 (20) 5 (16.7) 6 (20) 5 (16.7) 7 (23.3) 1 (3.3)
Qualitative themes

Thirty Black women PAs responded to the qualitative question in the survey to describe the gendered racial microaggressions they faced in the clinical setting. The qualitative responses were placed into 11 themes: gaslighting (3 responses), complacency (5), undermining authority (5), speech stereotypicality (3), angry Black woman stereotype (3), sexual objectification (4), insulting intelligence (9), White-passing (racial identity) (3), disrespectfulness (6), disbelief (2), and exhausting (2).

The insulting intelligence theme had significantly higher responses overall than the other themes. One respondent described insulting intelligence as patients “questioning my intelligence by asking for the doctor or questioning my treatment recommendations.” Another mentioned, “one guy said I looked too good to be a PA. Is that a real compliment? Are you insulting my intelligence and saying I couldn't possibly be pretty AND educated?” One PA was surprised when she “had a Black man question me about his wife's diagnosis. His wife was my patient and he demanded to see the doctor.” Black women PAs also experienced these insults from colleagues; as one person responded, “I have had colleagues question my authority even in front of patients. Even nurses who report to me would say, ‘Are you sure you want to give that dose of medicine?’”

The theme of disrespectfulness had the second-highest response rate. One respondent mentioned, “I had an older White patient tell me that I was pretty to be a Black girl. She kept calling me girl, too. It made me more sad than angry.” Another woman remarked that “they question your decisions, turn staff against you, sometimes in front of everyone.” Others described more pronounced disrespectfulness; for example, one respondent wrote, “I had a patient say that he was undressing me mentally with his eyes and then have the nerve to get mad when I told him he was being inappropriate and that I would no longer see him as a patient.”

Lastly, we identified an inverse relationship with White-passing (racial identity) and gendered racial microaggressions as well as speech stereotypicality and gendered racial microaggressions. One Black woman PA noted, “I haven't had a lot of these experiences before, but I think it is because I ‘look White.’” Another PA wrote, “I haven't experienced a lot of these.... I think it has more to do with me ‘passing’ as White.”

DISCUSSION

This study extended previous research on gendered racial microaggressions by examining their correlation with psychologic distress in Black women PAs. The first research question was answered by determining that Black women PAs experienced gendered racial microaggressions in clinical settings as evidenced by their responses to the frequency scale and personal experiences expressed. This is in line with previous studies that explored the various types of microaggressions Black women experienced.8,17 This study offers quantitative support to the study by Lewis, which uncovered three core gendered racial microaggression themes: projected stereotypes, silenced and marginalized, and assumptions about style and beauty.17 It also adds to the literature by demonstrating that despite the high achievement of becoming PAs, Black women are still subject to stereotypical images such as the angry Black woman and the strong Black woman. One study found that stereotypes of Black women, such as Jezebel and Superwoman, could hinder Black women's career potential.8

Results are mixed for the answer to the second research question. When viewing the quantitative data, Black women PAs experienced all four types of gendered racial microaggressions, but varying degrees of distress were associated with each type. Being silenced and marginalized was the most frequent and most stressful microaggression experienced. This makes intuitive sense because the job description of a PA in the clinical setting consists of diagnosing and treating patients, so it is more visible when a colleague, staff, or patient challenges the Black woman PA's medical decision-making.15 It adds a layer to previous research in which minority and female physicians felt that others challenged their assessments and questioned their qualifications.5,18,19

Although Black women PAs felt they experienced gendered racial microaggressions, for most Black women PAs, these experiences did not occur often. Regardless, previous studies have shown that racism does not have to be a daily occurrence to affect women.6,20 Women who identified as African Canadian did not report experiencing racism every week, but the awareness that it could arise at any moment was stressful.20 Sue and colleagues determined that, although microaggressions were small, subtle acts, the cumulative effect of these events was traumatic.6

The chi-square analyses revealed that some microaggressions were correlated with stress, which is parallel to other studies. As previous research suggests, gendered racial microaggressions, being silenced and marginalized, and assumptions about beauty and sexual objectification were associated with stress.16 Qualitative studies have shown that Black women often are reduced to stereotypes about their race and sex.4,8,21,22 Lewis uncovered situations in which assumptions about Black women's style and beauty and being silenced and marginalized were stressful and required coping mechanisms.21 Black women often used various coping mechanisms to deal with these microaggressions.21,22

Surprisingly, the quantitative data revealed no significant association between the strong Black woman microaggression and stress. The strong Black woman stereotype was not a qualitative theme, either. This is in contrast with a previous study that showed that these two variables were correlated.16 This could be because most PAs in this study felt being stereotyped as a strong Black woman was not stressful. Black PAs view the PA career as prestigious, so reframing this stereotype as being resilient could be seen as a coping mechanism.23,24 Another possible reason for the lack of correlation is that the PA profession could be a confounding variable. Although PAs are respected professionals, other medical professionals and policymakers have conflicting views about PAs' capabilities and responsibilities. PAs already are fighting to prove that they are intelligent enough to practice medicine with fewer restrictions, so Black women PAs may see being strong as a characteristic of the profession and not as a gendered racial microaggression.15

Another surprising result from the quantitative data was that no significant correlation was found between the angry Black woman microaggression and psychologic distress, although it was reflected as a theme in the qualitative data. This result diverges from a previous study that found that being viewed as an angry Black woman was stressful.16 Several reasons could explain these results. For the qualitative data, only three responses were coded as angry Black woman, reflecting that these were significant enough experiences that those PAs chose to write about them. Other respondents reflected on other experiences that were more significant to them, which parallels the quantitative data. Also, the very nature of the profession is a confounding variable. PAs are respected medical professionals and are held to a high ethical standard. Showing anger is unprofessional.15 This may be why most respondents did not feel they had experienced the angry Black woman microaggressions and why it is not associated with stress. This variable may need to be specifically adapted to the confines of a clinical setting, which may lead to a more accurate measure.4

Perhaps the strong Black woman and angry Black woman stereotypes were not significant because of the Black woman's ability to more easily manipulate the attributes that contribute to these microaggressions. A Black woman can control her voice, mannerisms, and conversation style by shifting her identity to align with what is viewed as meek and agreeable. She is being proactive in trying to prevent these stereotypes, and this is harder to do with other gendered racial microaggressions such as being silenced and marginalized or assumptions about beauty and sexual objectification.12 Just because the Black woman PA has partial control over those perceptions does not mean that control is positive or always effective. This is a burdensome coping mechanism.12,24,25 Perhaps the reason why these microaggressions present as less stressful is because Black women PAs are using coping mechanisms, such as shifting identity, which place unnecessary burdens on PAs and subtract from the mental energy that could be used for collaborating with the healthcare team and providing patient care.12,26

LIMITATIONS

This study used a convenience sample, only recruiting participants through Facebook. The lack of random sampling also could affect the study's generalizability. The anonymous format should, however, help with the participants' truthfulness. The survey format might have played a role in the results. All the frequency questions were asked first, and then all the stress appraisal questions were asked. The results may have been different if questions had been asked in a random order. Another limitation was that the survey asked for respondents' sex, but meant gender, because the survey was open to Black PAs who identified as women. Lastly, residual confounding may exist related to the lack of recognition of PAs' scope of practice. Future studies should compare gendered racial microaggressions among healthcare professionals (physicians, PAs, and NPs) to determine if the clinician's role is a factor regardless of race and gender.

CONCLUSIONS

Gendered racial microaggressions affect more than Black women PAs' physical and emotional health. These microaggressions have a ripple effect on the healthcare industry, team dynamics, and patient care. Mental resources are drained when a PA must shift through the ambiguity of microaggressions. Their focus is no longer on optimal patient care.26

This study has important implications for clinical practice. Gendered racial microaggressions harm mental health, reduce job satisfaction, and can affect patient safety.26,27 The experience of being devalued decreases the ability to perform complex cognitive tasks. Microaggressions undermine credibility and can lead to lower self-esteem, depression, anxiety, and trauma responses.13,28 Several studies have shown that when microaggressions start to affect job satisfaction, clinicians are at higher risk for burnout.26-29 This effect on mental health and job satisfaction can lead to patient harm. Jamal and colleagues reported that having a psychologically safe work environment is crucial for the trust and openness that let teams focus on high-quality, patient-centered care.27

PAs, their colleagues, and healthcare institutions must be aware that gendered racial microaggressions are associated with psychologic distress. Microaggressions affect Black women PAs, healthcare teams, and patients. Being aware of these occurrences can reduce the unknowing perpetuation of gendered racial microaggressions and offers opportunities to create cultural awareness practices in healthcare facilities.

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