The document discusses total health, being an ally, and unconscious bias. It provides examples of how unconscious biases can influence perceptions and behaviors, even among well-intentioned people. It also discusses techniques for measuring and addressing implicit biases, including contact with other groups, access to positive examples that challenge biases, and mindfulness. The goal is to promote fair treatment, respect, and eliminate discrimination.

1. Total Health, Being an Ally, and Unconscious Bias
Women’s Health - HLTH 471 University of Maryland, Shady Grove
September 15, 2015
Ted Eytan, MD, MS, MPH • Kaiser Permanente • @tedeytan
with instructor Sabrina Matoff-Stepp, Ph.D.
© 2015 The Permanente Federation, LLC
Photo: JaeLee Waldschmidt, by Ted Eytan, MD: https://flic.kr/p/t7AFya

2. A mother and her daughter are in a car accident.
The mother dies at the scene and the daughter,
badly injured, is rushed to the hospital. In the
operating room, the surgeon looks at the girl and
says, “I can’t operate on this girl. She is my
daughter.” How can this be?

3. The brain sees what it wants to see
“there is no immaculate perception”
A father and his son are in a car accident. The
father dies at the scene and the son, badly injured,
is rushed to the hospital. In the operating room,
the surgeon looks at the boy and says, “I can’t
operate on this boy. He is my son.” How can this
be?
Banaji, Mahzarin R.; Greenwald, Anthony G. (2013-02-12). Blindspot: Hidden Biases of Good People (Kindle Locations
1094-1096). Random House Publishing Group.

4. With Tessa Scheller, CRNA, and Nico Quintana, Basic Rights Oregon, Portland, OR USA • July 21, 2015
I’m an ally
(also a family doctor,
a Permanente physician,
a Kaiser Permanente member,
a Washington, DC resident)
Hi. I’m Ted.
(follow me @tedeytan)

5. I’m here from the future
Kaiser Permanente Center for Total Health, Washington, DC
kp.org/centerfortotalhealth • @KPTotalHealth

7. “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

9. Homophobia
makes me sick.
Canadian Rainbow Health Coalition
Coalition Santé Arc-en-ciel Canada
crhc
csac
Check in at outlive.ca
Homophobia
makes me sick.
No really it does. All that negative messaging
soaks into our skin like toxic radiation. How do
you get rid of it? Easy. Visit outlive.ca for the
little things you can do to take care of yourself.
They’re easy and you’re worth it.
Courtesy Transgender Health Information Program, Vancouver Coastal Health Authority • http://transhealth.vch.ca

11. source: http://itspronouncedmetrosexual.com/2013/05/silly-gender-comics/

12. It’s hard to be a transgender patient
EXCLUSION: “Services, drugs,
or supplies related to sex
transformation”

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

14. Source: http://www.unaids.org/
en/resources/infographics/
20140716_transgender

15. Transgender Day of Remembrance; Transgender Solidarity Rally & March
11/20/14 & 5/19/15 • http://www.flickr.com/photos/
22526649@N03/15817697336; http://www.flickr.com/photos/
22526649@N03/17795689395

16. 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

17. 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

18. 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

19. 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].

20. 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/; http://www.cbsnews.com/news/
ferguson-policing-eric-holder-implicit-explicit-racial-bias/
CBSNews, March, 2015
Facebook, Inc., 2015

21. Implicit Association Test

22. Implicit Association Test: I’m human

23. TRS-80 vs iPhone
1000x Speed Difference
Zilog Z80
1.77 MHz
Apple A8
1.4 GHz
"Apple A8 system-on-a-chip" by Henriok
- Own work. Licensed under CC0 via
Wikimedia Commons - http://
commons.wikimedia.org/wiki/
File:Apple_A8_system-on-a-
chip.jpg#mediaviewer/
File:Apple_A8_system-on-a-chip.jpg

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

25. Source: Source: Amodio, David, "The Neuroscience of Sterotyping and
Prejudice," New York University, http://www8.gsb.columbia.edu/leadership/
sites/leadership/files/David_Amodio_ColumbiaSept09.pdf

26. 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].

27. 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

28. 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

29. In the health of people who are trans* …
Clinician Implicit Bias
Quality of clinical
Encounters
Patient's Perceptions
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];http://www.metroweekly.com/2015/03/transgender-men-facing-discrimination-in-healthcare/
📓little research
😥few positive exemplars

30. In the health of their caregivers….
Medical students who are “out”
§ 68% : sexual identity
§ 34% : gender identity
only up from 44% two decades
ago (sexual identity)
Source: Mansh M, White W, Gee-Tong L, et al. Sexual and Gender Minority Identity Disclosure During Undergraduate Medical Education: “In the Closet” in Medical School. Acad.
Med. 2015;Publish Ah. Available at: http://journals.lww.com/academicmedicine/Fulltext/publishahead/Sexual_and_Gender_Minority_Identity_Disclosure.98848.aspx.
In interacting with residents and
attendings, it is clear through general
conversation and offhand comments that LGBT is
unfamiliar and, at best, a joke. (26-year-old,
third-year, gay, white, male, U.S. MD
student)
On my surgery rotation, we saw a male- to-
female transgender patient who had “do-it-
yourself ” silicone breast implants which had
become infected. He [sic] was treated like a
freak by the residents and attendings behind
closed doors, joking at his [sic] expense. (25-
year-old, third-year, lesbian, white, female,
U.S. MD student)

31. Where do implicit biases come from?
"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)

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

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

34. Can we eliminate it? Is it malleable?
Source: Source: Amodio, David, "The Neuroscience of Sterotyping and
Prejudice," New York University, http://www8.gsb.columbia.edu/leadership/
sites/leadership/files/David_Amodio_ColumbiaSept09.pdf
Yes!
😉

35. If you don’t like the world the way it is, change it
“Rider” - eliminated
“Exclusions” - eliminated
Medically necessary care,
including surgery, must be
covered, in all plans,
including individual and
group
All DC Government plans
now include medically
necessary care Chester McPherson, Insurance Commissioner
Washington, DC ends discrimination in health insurance
February 27, 2014

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

37. Ruby Jade Corado, Humanist-Transgender woman, Mayor Vince Gray, Washington, DC
October 18, 2014 • http://www.flickr.com/photos/22526649@N03/14958436953

38. 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

39. 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

40. Juliet Greenwood, PhD
Associate Dean for Academic and Student Affairs
Associate Professor, Biochemistry and Biophysics
Oregon State University
Source: Juliet Greenwood, PhD

41. Ruby Jade Corado • Ted Eytan
Stonewall LGBTQ & Allies Athletic League, Washington, DC USA • February 12, 2015

42. New York Times: Transgender today
http://www.nytimes.com/interactive/projects/storywall/transgender-today/stories/brynn-tannehill

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

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

45. Debiasing Techniques that you should promote
Measure: Implicit Association Test
– Encourage, don’t mandate
Reframe
– From: Discrimination, Protected Class
– To: Fair treatment, Respect
Question
– The illusion of objectivity

46. Today : A world learning to love better
“Skyzone”
http://j.mp/edithbunkerally
March 15, 2014
Source: http://xfinity.comcast.net/blogs/tv/2014/03/14/exclusive-clip-undercover-boss-
features-transgender-employee/; http://transhealth.vch.ca
Transgender Health Information Program
Vancouver Coastal Health Authority
March 19, 2015

47. Yes to more.
Yes to more me. More massages. More laughter.
More friends. More intimacy. More sleep. More
water. More bike rides. More visits to a doctor
or therapist. Yes to vitamins. Yes to one more
salad this week. Yes to more dancing. Yes to
more life. Yes to outliving homophobia.Canadian Rainbow Health Coalition
Coalition Santé Arc-en-ciel Canada
crhc
csac
Yes to more.
Yes to more me. More massages. More laughter.
More friends. More intimacy. More sleep. More
water. More bike rides. More visits to a doctor
or therapist. Yes to vitamins. Yes to one more
salad this week. Yes to more dancing. Yes to
more life. Yes to outliving homophobia.
Check in at outlive.ca
Courtesy Transgender Health Information Program, Vancouver Coastal Health Authority • http://transhealth.vch.ca

48. KPLantern: Human Centered Field Work
KPLantern Synthesis, Oakland, CA USA
April 8, 2015 • http://www.flickr.com/photos/22526649@N03/16901602669

49. #CTHNext: Social Innovation

53. Exterior: Total Health Across America Digital Wall • Center for Total Health
June, 2015