2014.05.02 Being a Transgender Ally and Unconscious Bias

Being a Transgender Ally and Unconscious Bias 
Kaiser Permanente 2nd Annual LGBTQI Symposium:
Advancing LGBTI Health Equity
May 2, 2014 | Universal City, California, USA
Ted Eytan, MD, MS, MPH • The Permanente Federation, LLC • @tedeytan
with April Soto, MD & Prudence (Kaiser Permanente member)
© 2014 The Permanente Federation, LLC

Intended Learning Outcomes & Disclosure
At the conclusion of this keynote, learners should be able to
Understand the role of ally in LGBTQI health
Understand the difference between explicit and implicit bias
Understand how to measure implicit bias
Be able to recognize behaviors consistent with implicit and explicit bias across
the lesbian, gay, bisexual, transgender, and intersex individuals we serve
Engage in activities to eliminate implicit bias in the clinical setting and beyond,
as an ally, to promote equality in the health and health care of LGBTQI
individuals at Kaiser Permanente and beyond
Disclosure
"I do not have any relevant financial relationships to disclose."

Intended Learning Outcomes & Disclosure
What’s unconscious bias and why should I care?
What causes it?
I’m a clinician / leader / citizen - what can I do about it?
!
!
Disclosure
I 😄 Kaiser Permanente!

Hi. I’m Ted.
with Dana Beyer, MD, ﬁrst trans Senate candidate in American history • SMYAL Fall Brunch • Washington, DC
Kaiser Permanente Titanium Sponsor, 2013
I’m a trans* ally
(also a family doctor,
a Permanente physician,
a Kaiser Permanente member,
a Washington, DC resident)

We’re here from the future
Kaiser Permanente Center for Total Health,Washington, DC • @KPTotalHealth

So are you.
Kaiser Permanente LGBTQI Health Symposium, Los Angeles, CA • April 13, 2013

Anna Pitinyan, RN, BSN • Tisha Baird, MD
Transgender Person Care & Endocrinology
Kaiser Permanente Los Angeles Medical Center • May 1, 2014

Why we’re having this dialogue
ALL of us
– have biases
– are human beings
– want to be the best
for the human
beings we serve
Yes, ALL of us
“..biases that we do not
acknowledge but that persist,
unchallenged, in the recesses
of our minds, undoubtedly
shape our society.” -
Rudman, 2004

How we’re having this dialogue
Use of language
– “discrimination,” “homophobia,” “bias”
– if defensive, notice it and accept the
discomfort of unlearning and
relearning.
– “This requires a desire to know,
motivation to become informed,
willingness to correct mistakes”
Personality lens
– Amiable-amiable with a z versatility
– aka “Double rainbow,” “Glass 3/4 full”
Source: http://www.cookross.com/docs/UnconsciousBias.pdf

Drs. Jennifer Slovis, Susanne Watson, and Judy Lively • Community Partner awards
Transgender Law Center Annual Gala, San Francisco, CA • October 3, 2013
http://www.ﬂickr.com/photos/22526649@N03/10327667743

Rebecca Goldfader, ARNP • Community Partner awards
Transgender Law Center Annual Gala, San Francisco, CA • October 3, 2013

The brain sees what it wants to see
“there is no immaculate perception”
Source:Shepard, Roger, Mind Sights: Original Visual Illusions, Ambiguities, and Other
Anomalies, New York, W.H. Freeman and Company, 1990

The brain sees what it wants to see
“there is no immaculate perception”
Source:http://en.wikipedia.org/wiki/File:Peripheral_drift_illusion_rotating_snakes.svg

we use tools to help us see accurately…
Bocce in the Park, Meridian Hill Park, Washington, DC, USA, April 20, 2014
Source: Ted Eytan, MD, http://www.ﬂickr.com/photos/22526649@N03/13957191713

Explicit Attitudes = aware, endorsed
Ability to claim as our own
– “We oppose discrimination in all
forms”
– “When I look back I want to be
on the right side of history”
Measured by asking
“This ability to examine the
contents of our own minds
and manipulate them is
uniquely human.”
Negative attitudes, relative to whites
Source: Phelan SM, Dovidio JF, Puhl RM, et al. Implicit and explicit weight
bias in a national sample of 4,732 medical students: The medical student
CHANGES study. Obesity (Silver Spring). 2014;22(4):1201–8. Available at:
http://www.ncbi.nlm.nih.gov/pubmed/24375989 [Accessed April 2, 2014].

Implicit Attitudes = unconscious, automatic
“Ultimately, we believe our decisions
are consistent with our conscious
beliefs, when in fact, our unconscious
is running the show”
Not accessible through introspection
Measured indirectly
Noticed directly!
Active area of study in employment,
law, education, medicine, across
industries
Source: Staats C. State of the Science: Implicit Bias Review 2014. Columbus, OH; 2014. Available at: http://kirwaninstitute.osu.edu/
implicit-bias-review/.,http://armylgbt.org.uk/army-reserve-quarterly-features-army-lgbt-conference/
Young
Reserve
Officer’s
Workshop
Brno,
Czech Republic
YROW is an annual week-long
programme run by the Interallied
Confederation of Reserve Officers
(CIOR) and is designed to be a
young officer's first international
exposure to colleagues from NATO
and its Partners.
Dates: 29 Jul to 3 Aug 2013.
Location: Brno, Czech Republic
Open to: TA junior officers
(2Lt to Capt)
YROW is sponsored by HQ Army,
eligible for MTDs, and all travel costs
are covered including flights etc.
It consists of a week of seminars,
practical exercises, command tasks
and a lot of social interaction with
about 18 other NATO member states.
A social, interesting, and useful
week of getting to know the
“The attendance of those in the chain of
command at the conference demonstrates a
marked and increasing commitment to good
management practices in the Army.
The Army aims to create a working
environment in which everyone can be
authentic about themselves, because
it improves operational effectiveness,”
concludes Major Jenkins.
The next LGBT conference is for all services in
the Armed Forces, and will be organised by
the Royal Navy at MOD Main Building on
28 June 2013.
TA
soldiers from the
Lesbian Gay Bisexual
and Transgender (LGBT)
community met those in the chain of
command at the third annual Army
LGTB conference held in March.
The theme of this year’s conference was
“Cultivating LGBT Talent” to address the fact
that there are few visibly LGBT soldiers or
officers in senior roles despite recent statistics
from Phase 1 and 2 recruits indicating that
around one in six new soldiers joining their
units in 2013 are in this group.
“The concern is that LGBT senior soldiers and
officers feel unable to be open about their
sexual orientation or gender identity, or that
they leave before achieving senior positions,”
explains Major Damian Jenkins, chairman of
the Army LGBT Forum.
“We don’t know how big the Army LGBT
community is, but the first Army-gathered
statistics on gender identity and sexual
Conference
Confronts
Unconscious
Biases
37
UK Army LGTB Conference, 2013

Rebecca Goldfader, ARNP, Kaiser Permanente San Francisco, January 29, 2014

Deb Friesen, MD and Rachael St.Claire, PsyD
Receipt of Human Rights Campain, 100%
Corporate Equality Index Award, April 1,
2014, New York City, NY
National Diversity and Inclusion Conference,
Kaiser Permanente, November 22, 2013, San
Francisco, CA

Brenda McComb, PhD
Trustee, Oregon State University (with Provost Sabah Randhawa)
Dean of Graduate Programs, Oregon State University
Professor of Forestry
Trans* Ally
Source: http://oregonstate.edu/leadership/trustees; http://pinterest.com/oregontrans

Being an ally in a world less loving
“Edith’s Crisis of Faith,” All in the Family, air date 12/25/1977
https://www.youtube.com/watch?v=xDY_S8YO5QY

Bias: a generation ago
“Edith’s Crisis of Faith,” All in the Family, 1977
https://www.youtube.com/watch?v=xDY_S8YO5QY

Nico Quintana, Rally for Transgender Health Equality, Washington DC • March 30, 2013
https://ﬂic.kr/p/e7nVNC

Rally for Transgender Health Equality, Washington DC • March 30, 2013

It’s hard to be an ally
“Will they want
cross-species
transplants next?”“Not all medical
groups share “Ted’s”
point of view”“Ted, people with
HIV were dying” “I
fully expect the numbers
to increase”
“Ted, are you a t—-y?”
“Wasn’t that
stabbing victim a
sex worker?”
“You’re violating HIPAA”
Source: http://dcist.com/2013/06/transgender_woman_stabbed_up_to_40.php

quick answers…
No
I think they believe in science, though
Yes, and we’re saddened by it, too
Yes, more human beings able to live
their lives through better health
If it recruits your humanity, believe that
I am. And, you can never say that word
in front of me again.
Many humans who are (illegally)
denied employment are.
“Receiving anger is a sacred task” -
(Ronald Heifetz, Leadership on the Line)

It’s harder to be a patient
“We need
to understand what
our competition is
doing”
“This is
cosmetic / aesthetic
surgery”“Care is very
expensive”
EXCLUSION: “Services, drugs,
or supplies related to sex
transformation”
“Top Surgery has not been
universally accepted as treatment
for transgender Dysphoria [sic] - its
considered ‘elective'."“Top Surgery is reserved for
breast cancer patients and members
who have purchased the
'Transgender Rider’"

What does our history tell us?
Incorrect - AMA H-158.950
Incorrect - Multiple actuarial
analyses declared “de minimis”,
“immaterial”,”insignificant”
Incorrect - AMA H-158.950
Is this Fair Treatment?
– American Medical Association, District of
Columbia, 6 other states, Title VII, and
the Affordable Care Act
– sex discrimination now includes gender
identity and expression
– “in contradiction to the medical
profession’s prized values of equity and
respect”
quick answers…
Sources: American Medical Association H-185.950, Economic Impact Assessment,
Gender Nondiscrimination in Health Insurance, State of California, OCR Transaction
Number: 12-000800, DC Dept of Insurance, Securities and Banking, Affordable Care
Act, Section 1557, Holder, et. al, Appeal No. 0120120821,1. Stroumsa D. The state of
transgender health care: policy, law, and medical frameworks. Am. J. Public Health.
2014;104(3):e31–8. Available at: http://ajph.aphapublications.org/doi/abs/10.2105/
AJPH.2013.301789 [Accessed April 3, 2014].

It’s hardest to just be…
http://www.contracostatimes.com/walnut-creek/ci_24475186/walnut-creek-woman-
found-i-680-identiﬁed

31
Paul de Kruiff, Kaiser wakes the Doctors, 1943

Being a Transgender Ally and Unconscious Bias 
Kaiser Permanente 2nd Annual LGBTQI Symposium:
Advancing LGBTI Health Equity
May 2, 2014 | Universal City, California, USA
Ted Eytan, MD, MS, MPH • The Permanente Federation, LLC • @tedeytan
with April Soto, MD & Prudence (Kaiser Permanente member)
© 2014 The Permanente Federation, LLC
Desert Center, 1933

“Black patients are to be treated like everybody else. There is no segregation at our
facilities.”- Henry J. Kaiser (digital display, Kaiser Permanente Center for Total Health, 2011)

Sylvia Rae Rivera (1951 – 2002) American bisexual transgender activist and trans woman
http://highkixx.com/2012/01/

Marsha P Johnson, 1944-1992, Black Transgender Rights Activist

Ruby Jade Corado, D.C. Humanist-Transgender woman, Casa Ruby DC, Washington, DC
February 25, 2014 • http://www.ﬂickr.com/photos/22526649@N03/12784261603

Biology, not intention (mostly)
“since wars begin in the minds of
men, it is in the minds of men
that the defences of peace must
be constructed”
– 1947 constitution of UNESCO – the
United Nations Educational, Scientific
and Cultural Organization
It’s just biology
We’re all biased
That’s boring
It’s what you do with it that matters
Denise Lascar, Trans* Ally, Ruff Plastic Surgery
Washington, DC • October 8, 2013

Implicit Association Test (IAT)
Developed 1998
Easily taken at http://projectimplicit.net
KP Learn: “Unconscious bias”
#00643343
Available for bias in age, weight,
gender, sexual orientation
– currently no test for gender identity/
expression
About 5 minutes long
“The IAT has demonstrated enough
reliability and validity that total denial is
implausible” (Kang & Lane, 2010)
Sangeeta Iyer, MD, Internal Medicine Specialist
Transgender services champion
Kaiser Permanente Capitol Hill Medical Center
Washington, DC

Tessa Scheller, CRNA
Certified Registered Nurse
Anesthetist
Kaiser Permanente Northwest
Retired 2008
Kaiser Permanente member
advisor, national transgender
champions group (as of 2014)

Community leaders Ruby Corado and Melanie Hiller • Washington, DC • March 27, 2014

TRS-80 vs iPhone
1000x Speed Difference
Zilog Z80
1.77 MHz
Apple A7
1.3 GHz

Conscious vs Unconscious
687,500x Speed Difference - Brain wins!
16-40 bits/second
11,000,000 bits/second

Conscious vs Unconscious
687,500x Speed Difference - Brain wins!
Source: Stanley D, Phelps E, Banaji M. The Neural Basis of Implicit Attitudes. Curr. Dir. Psychol. Sci. 2008;17(2):164–170.
[Accessed April 1, 2014].

Your brain on walking - same pathways (?)
activated
activated
activated
deactivated
it works better
Source: Hillman CH, Erickson KI, Kramer AF. Be smart, exercise your heart: exercise effects on brain and cognition. Nature Reviews. Neuroscience. 2008;9(1):58–65..
Slide created by Ted Eytan, MD | @tedeytan | December, 2012

LGBT Health Awareness Week • March 25, 2013
Kaiser Permanente Center for Total Health
With Paula Woodward (American College of Physicians), Susan Rowe, Margo Williams (ACP)

Charing Cross Gender Identity Clinic, London, GB
James Barrett, MD, Lead Clinician
Charing Cross GIC, London, GB

Implicit attitudes inﬂuence behavior
Resident Physicians, 2007
– Reduced likelihood to prescribe
thrombolytics for African American patients
associated with implicit bias
– Higher likelihood of prescribing
thrombolytics for African Americans if they
were aware of what the study was
measuring
Survey based study
28% response rate
Source: Green AR, Carney DR, Pallin DJ, et al. Implicit bias among physicians and its prediction of thrombolysis decisions for black and
white patients. J. Gen. Intern. Med. 2007;22(9):1231–8. Available at: http://www.pubmedcentral.nih.gov/articlerender.fcgi?
artid=2219763&tool=pmcentrez&rendertype=abstract [Accessed January 28, 2014], Staats C. State of the Science: Implicit Bias Review
2014. Columbus, OH; 2014. Available at: http://kirwaninstitute.osu.edu/implicit-bias-review/.
Resident Physicians, 2007

Impact: hypertension control
Blair, et. al
– Kaiser Permanente &
Denver Health
– 210 Physicians
– 190 Community Members
– 4,794 patients
Clinician Implicit Bias
Quality of clinical
Encounters
Patient's Perceptions
of Physician
Medication
Adherence
Hypertension
Control
Clincian's
Perceptions and
Judgements of
Patient
Treatment
Intensiﬁcation
Source: Blair I V, Steiner JF, Hanratty R, et al. An Investigation of Associations Between
Clinicians’ Ethnic or Racial Bias and Hypertension Treatment, Medication Adherence and
Blood Pressure Control. J. Gen. Intern. Med. 2014:18–20. Available at: http://
www.ncbi.nlm.nih.gov/pubmed/24549521, Blair I, Steiner J. Clinicians’ implicit ethnic/racial
bias and perceptions of care among black and Latino patients. Ann. Fam. …. 2013:43–52.
Available at: http://www.annfammed.org/content/11/1/43.short [Accessed April 21, 2014].
Blair I V, Havranek EP, Price DW, et al. Assessment of biases against Latinos and African
Americans among primary care providers and community members. Am. J. Public Health.
2013;103(1):92–8. Available at: http://www.pubmedcentral.nih.gov/articlerender.fcgi?
artid=3518332&tool=pmcentrez&rendertype=abstract [Accessed March 29, 2014].

Impact: hypertension control
Quality of clinical
Encounters
of Physician
Medication
Adherence
Hypertension
Control
Clincian's
Perceptions and
Judgements of
Patient
Treatment
Intensiﬁcation
72 - 82% preference for Whites
Lower if Black, Latino
Black: proportional to implicit bias
No difference: White, Black, Latino
Lower if Black, Latino
NOT related to implicit bias
Lower if Black
NOT related to implicit bias
Source: Blair I V, Steiner JF, Hanratty R, et al. An Investigation of Associations Between Clinicians’ Ethnic or Racial Bias and Hypertension Treatment,
Medication Adherence and Blood Pressure Control. J. Gen. Intern. Med. 2014:18–20. Available at: http://www.ncbi.nlm.nih.gov/pubmed/24549521,
Blair I, Steiner J. Clinicians’ implicit ethnic/racial bias and perceptions of care among black and Latino patients. Ann. Fam. …. 2013:43–52. Available
at: http://www.annfammed.org/content/11/1/43.short [Accessed April 21, 2014]. Blair I V, Havranek EP, Price DW, et al. Assessment of biases against
Latinos and African Americans among primary care providers and community members. Am. J. Public Health. 2013;103(1):92–8. Available at: http://
www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3518332&tool=pmcentrez&rendertype=abstract [Accessed March 29, 2014].
18% - 28% of physicians WITHOUT implicit bias

In the health of people who are trans* …
Quality of clinical
Encounters
of Physician
Treatment
adherence
medically
necessary care
Clincian's
Perceptions and
Judgements of
Patient
Treatment
recommendation
Adapted from Blair I V, Steiner JF, Hanratty R, et al. An Investigation of Associations Between Clinicians’ Ethnic or Racial Bias and
Hypertension Treatment, Medication Adherence and Blood Pressure Control. J. Gen. Intern. Med. 2014:18–20. Available at: http://
www.ncbi.nlm.nih.gov/pubmed/24549521 [Accessed April 12, 2014].

In the health of people who are trans* …
Quality of clinical
Encounters
of Physician
Treatment
adherence
medically
necessary care
Clincian's
Perceptions and
Judgements of
Patient
Treatment
recommendation
😠explicit clinician bias ⛔️ denial of coverage
💉 self administration
😠explicit & implicit insurance bias
💰no employment
⚠️clinical competence 😠implicit patient bias
🚬no preventive care
Source: https://twitter.com/TRANSLATINAS_NY/statuses/304597877425049600; http://www.dailykos.com/story/2014/04/18/1292952/-Illinois-Transwoman-Refused-Medical-
Care-Because-Religious-Freedom?showAll=yes, adapted from Adapted from Blair I V, Steiner JF, Hanratty R, et al. An Investigation of Associations Between Clinicians’ Ethnic or
Racial Bias and Hypertension Treatment, Medication Adherence and Blood Pressure Control. J. Gen. Intern. Med. 2014:18–20. Available at: http://www.ncbi.nlm.nih.gov/pubmed/
24549521 [Accessed April 12, 2014].
📓little research
😥few positive exemplars

Capital Pride, Washington DC • Kaiser Permanente Silver Sponsor • June 8, 2013

Baltimore Pride, June 15, 2013, Baltimore, MD, USA

Caprice Williams, Mayor Vince Gray, Consuela Lopez, Andy Bowen, Washington, DC
March 6, 2014 • http://www.ﬂickr.com/photos/22526649@N03/12998223535

Where do implicit biases come from?
Accrued and change passively
Documented in children as young as 6 years old
Nature/Nurture : YES
– Our commitment is to be fair regardless
"Wrong information always shown by the media
Negative images is the main criteria
Infecting the young minds faster than bacteria
Kids wanna act like what they see in the cinema"
!
Black Eyed Peas, Where is the Love (2003)

http://walnutcreek.patch.com/
groups/police-and-ﬁre/p/
pedestrian-killed-after-being-
hit-by-a-car-on-walnut-creek-
freeway

Source: http://yaledailynews.com/blog/2013/04/26/yale-
health-extends-sex-reassignment/#comment-879479376
And then there was the Yale Daily News

And then there was the Yale Daily News
Source: http://
yaledailynews.com/
blog/2011/11/14/
brain-scans-measure-
racial-bias/

Bianca Rey, Melanie Hiller, with E.W. Emanuel, MD, Capital TransPride, Washington, DC
May 18, 2013 • http://www.ﬂickr.com/photos/22526649@N03/8752145070

Lane Hudson, Community Leader, and Ruby Jade Corado, D.C. Humanist-Transgender
woman Washington, DC • March 27, 2014

Can we eliminate it? Is it malleable?
“There is a pretty obvious reason for
this: 90% of the mug shots in my local
paper are blacks.”
“What hope is there, however, to
exterminate my acknowledged
implicit bias which is clearly based
on seeing the world the way it
exists (alas)?”
Source: http://annfammed.org/content/11/1/43.full/reply#annalsfm_el_25471
Yes!
😉

If you don’t like the world the way it is, change it.
February 27, 2014, Washington, DC USA

If you don’t like the world the way it is, change it
“Rider” - must be eliminated
“Exclusions” - must be eliminated
Medically necessary care,
including surgery, must be
covered, in all plans, including
individual and group
All DC Government plans will
include medically necessary care
New plans must be filed within
90 days
Chester McPherson, Insurance Commissioner, Washington, DC
February 27, 2014

Debiasing Techniques that you can should use
Contact
– “Involving equal status, cooperation
to achieve common goals, and
supported by important societal
institutions”– “

– Intergroup
– Extended
– Imagined
Access to positive exemplars
Mindfulness
“If this, then that”
“Life is for Living, Now I Can!” - Beth
Charing Cross GIC, London, GB

Debiasing Techniques that you should promote
Measure: Implicit Association Test
– Encourage, don’t mandate
Reframe
– From: Discrimination, Protected Class
– To: Fair treatment, Respect
Question: Illusion of objectivity
Create: “Tell me more” culture
Include: Instruction in social
psychology of stereotyping and
prejudice

Exercise
Spend the next 60 seconds imagining
yourself meeting a person who is
transgender for the first time. Imagine
that the interaction is relaxed, positive,
and comfortable
Now, List as many things as you can
about the interaction that you just
imagined
Source: Turner RN, Crisp RJ. Imagining intergroup contact reduces implicit
prejudice. Br. J. Soc. Psychol. 2010;49(Pt 1):129–42. Available at: http://
www.ncbi.nlm.nih.gov/pubmed/19302731 [Accessed March 25, 2014].

“As gay young people, we are marginalized. As young people who are HIV-
positive and have AIDS, we are totally written off.” – Pedro Zamora, 1972 -1994

Walkway in front of Kaiser Permanente Los Angeles Medical Center, Los Angeles

We’re all misﬁts with a dream (of better health)

Today : A world learning to love better
“Skyzone” - March 15, 2014
Source: http://xﬁnity.comcast.net/blogs/tv/
2014/03/14/exclusive-clip-undercover-boss-
features-transgender-employee/

“Breckin and Jeff” - Undercover Boss (CBS)
Source: https://www.youtube.com/watch?v=44ghpWc5qrI (air date 3/15/2014)

Advice from experts
“own the fact the fact that you’re not exceptional. you are in this sweet
spot of judges, lawyers, police, all of whom have bias. If you care, it would
make sense to find out.” - Jerry Kang, JD, Professor of Law, UCLA
April 15, 2014
“Don’t present this as scary. This behavior is malleable
and contextually sensitive.”
- Irene Blair, Phd, Associate Professor, Psychology and
Neuroscience, University of Colorado
April 11, 2014
“If there is one bisexual man in your unit his fitting in
depends on how open to diversity your unit is. It is NOT
based on how hard he tries to fit in.” - Sasha Scott & Damian
Jenkins, UK LGTB Army Forum
June, 2013

Bianca Rey and Melanie HIller, Ofﬁcers in KP Pride Mid-Atlantic States, Martin Luther King Jr. Memorial Library
Washington, DC, • Feb 25.2014 • http://www.ﬂickr.com/photos/22526649@N03/12791074333

Bianca Rey, Bestselling Author Janet Mock, Melanie Hiller • Washington, DC • Feb 25, 2014

Stonewall Bocce, Logan Circle, Washington, DC • October 31, 2013

2014.05.02 Being a Transgender Ally and Unconscious Bias

2014.05.02 Being a Transgender Ally and Unconscious Bias

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2014.05.02 Being a Transgender Ally and Unconscious Bias