2014.05.02 Being a Transgender Ally and Unconscious Bias

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Keynote, 2nd annual Kaiser Permanente LGBTQI Health Symposium. About unconscious/implicit bias, in the setting of transgender person health. Sheraton Universal, Universal City, California

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2014.05.02 Being a Transgender Ally and Unconscious Bias

  1. 1. 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
  2. 2. 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."
  3. 3. 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!
  4. 4. 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)
  5. 5. We’re here from the future Kaiser Permanente Center for Total Health,Washington, DC • @KPTotalHealth
  6. 6. So are you. Kaiser Permanente LGBTQI Health Symposium, Los Angeles, CA • April 13, 2013
  7. 7. Anna Pitinyan, RN, BSN • Tisha Baird, MD Transgender Person Care & Endocrinology Kaiser Permanente Los Angeles Medical Center • May 1, 2014
  8. 8. 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
  9. 9. 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
  10. 10. 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
  11. 11. Rebecca Goldfader, ARNP • Community Partner awards Transgender Law Center Annual Gala, San Francisco, CA • October 3, 2013 http://www.flickr.com/photos/22526649@N03/10327667743
  12. 12. 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
  13. 13. 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
  14. 14. 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
  15. 15. 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].
  16. 16. 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
  17. 17. Rebecca Goldfader, ARNP, Kaiser Permanente San Francisco, January 29, 2014
  18. 18. 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
  19. 19. 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
  20. 20. Bias - 1975
  21. 21. 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
  22. 22. Bias: a generation ago “Edith’s Crisis of Faith,” All in the Family, 1977 https://www.youtube.com/watch?v=xDY_S8YO5QY
  23. 23. Nico Quintana, Rally for Transgender Health Equality, Washington DC • March 30, 2013 https://flic.kr/p/e7nVNC
  24. 24. Rally for Transgender Health Equality, Washington DC • March 30, 2013 http://www.flickr.com/photos/22526649@N03/8603716639
  25. 25. 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
  26. 26. 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)
  27. 27. 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’"
  28. 28. 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].
  29. 29. It’s hardest to just be… http://www.contracostatimes.com/walnut-creek/ci_24475186/walnut-creek-woman- found-i-680-identified
  30. 30. 31 Paul de Kruiff, Kaiser wakes the Doctors, 1943
  31. 31. 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
  32. 32. “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)
  33. 33. Sylvia Rae Rivera (1951 – 2002) American bisexual transgender activist and trans woman http://highkixx.com/2012/01/
  34. 34. Marsha P Johnson, 1944-1992, Black Transgender Rights Activist
  35. 35. Ruby Jade Corado, D.C. Humanist-Transgender woman, Casa Ruby DC, Washington, DC February 25, 2014 • http://www.flickr.com/photos/22526649@N03/12784261603
  36. 36. 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
  37. 37. 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
  38. 38. Implicit Association Test
  39. 39. Implicit Association Test
  40. 40. Tessa Scheller, CRNA Certified Registered Nurse Anesthetist Kaiser Permanente Northwest Retired 2008 Kaiser Permanente member advisor, national transgender champions group (as of 2014)
  41. 41. Community leaders Ruby Corado and Melanie Hiller • Washington, DC • March 27, 2014 http://www.flickr.com/photos/22526649@N03/13464925243
  42. 42. TRS-80 vs iPhone 1000x Speed Difference Zilog Z80 1.77 MHz Apple A7 1.3 GHz
  43. 43. Conscious vs Unconscious 687,500x Speed Difference - Brain wins! 16-40 bits/second 11,000,000 bits/second
  44. 44. 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].
  45. 45. 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
  46. 46. 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) http://www.flickr.com/photos/22526649@N03/8589989716
  47. 47. Charing Cross Gender Identity Clinic, London, GB James Barrett, MD, Lead Clinician Charing Cross GIC, London, GB
  48. 48. 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
  49. 49. 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].
  50. 50. Impact: hypertension control 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 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
  51. 51. 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 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].
  52. 52. 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]. 📓little research 😥few positive exemplars
  53. 53. Capital Pride, Washington DC • Kaiser Permanente Silver Sponsor • June 8, 2013 http://www.flickr.com/photos/22526649@N03/8997223970
  54. 54. Baltimore Pride, June 15, 2013, Baltimore, MD, USA http://www.flickr.com/photos/22526649@N03/9060217825
  55. 55. Caprice Williams, Mayor Vince Gray, Consuela Lopez, Andy Bowen, Washington, DC March 6, 2014 • http://www.flickr.com/photos/22526649@N03/12998223535
  56. 56. 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)
  57. 57. http://walnutcreek.patch.com/ groups/police-and-fire/p/ pedestrian-killed-after-being- hit-by-a-car-on-walnut-creek- freeway
  58. 58. Source: http://yaledailynews.com/blog/2013/04/26/yale- health-extends-sex-reassignment/#comment-879479376 And then there was the Yale Daily News
  59. 59. And then there was the Yale Daily News Source: http:// yaledailynews.com/ blog/2011/11/14/ brain-scans-measure- racial-bias/
  60. 60. Bianca Rey, Melanie Hiller, with E.W. Emanuel, MD, Capital TransPride, Washington, DC May 18, 2013 • http://www.flickr.com/photos/22526649@N03/8752145070
  61. 61. Lane Hudson, Community Leader, and Ruby Jade Corado, D.C. Humanist-Transgender woman Washington, DC • March 27, 2014 http://www.flickr.com/photos/22526649@N03/13465159024
  62. 62. 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! 😉
  63. 63. If you don’t like the world the way it is, change it. February 27, 2014, Washington, DC USA
  64. 64. 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
  65. 65. 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
  66. 66. 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
  67. 67. 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].
  68. 68. Odd to be an ally?
  69. 69. “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
  70. 70. Walkway in front of Kaiser Permanente Los Angeles Medical Center, Los Angeles
  71. 71. We’re all misfits with a dream (of better health)
  72. 72. 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/
  73. 73. “Breckin and Jeff” - Undercover Boss (CBS) Source: https://www.youtube.com/watch?v=44ghpWc5qrI (air date 3/15/2014)
  74. 74. 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
  75. 75. 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
  76. 76. Bianca Rey, Bestselling Author Janet Mock, Melanie Hiller • Washington, DC • Feb 25, 2014 http://www.flickr.com/photos/22526649@N03/12784562863
  77. 77. Nico Quintana, Rally for Transgender Health Equality, Washington DC • March 30, 2013 https://flic.kr/p/e7nVNC
  78. 78. Rebecca Goldfader, ARNP, Kaiser Permanente San Francisco, January 29, 2014
  79. 79. 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
  80. 80. Stonewall Bocce, Logan Circle, Washington, DC • October 31, 2013 http://www.flickr.com/photos/22526649@N03/12219983155
  81. 81. Rebecca Goldfader, ARNP • Community Partner awards Transgender Law Center Annual Gala, San Francisco, CA • October 3, 2013 http://www.flickr.com/photos/22526649@N03/10327667743
  82. 82. Capital Pride, Washington DC • Kaiser Permanente Silver Sponsor • June 8, 2013 http://www.flickr.com/photos/22526649@N03/8997223970
  83. 83. Community leaders Ruby Corado and Melanie Hiller • Washington, DC • March 27, 2014 http://www.flickr.com/photos/22526649@N03/13464925243
  84. 84. 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) http://www.flickr.com/photos/22526649@N03/8589989716
  85. 85. Rally for Transgender Health Equality, Washington DC • March 30, 2013 http://www.flickr.com/photos/22526649@N03/8603716639
  86. 86. Tessa Scheller, CRNA Certified Registered Nurse Anesthetist Kaiser Permanente Northwest Retired 2008 Kaiser Permanente member advisor, national transgender champions group (as of 2014)
  87. 87. Ruby Jade Corado, D.C. Humanist-Transgender woman, Casa Ruby DC, Washington, DC February 25, 2014 • http://www.flickr.com/photos/22526649@N03/12784261603
  88. 88. 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
  89. 89. Ruby Jade Corado, D.C. Humanist-Transgender woman, Casa Ruby DC, Washington, DC February 25, 2014 • http://www.flickr.com/photos/22526649@N03/12784261603
  90. 90. Baltimore Pride, June 15, 2013, Baltimore, MD, USA http://www.flickr.com/photos/22526649@N03/9060217825
  91. 91. Ruby Jade Corado, D.C. Humanist-Transgender woman, Casa Ruby DC, Washington, DC February 25, 2014 • http://www.flickr.com/photos/22526649@N03/12784261603
  92. 92. Caprice Williams, Mayor Vince Gray, Consuela Lopez, Andy Bowen, Washington, DC March 6, 2014 • http://www.flickr.com/photos/22526649@N03/12998223535
  93. 93. 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
  94. 94. Bianca Rey, Bestselling Author Janet Mock, Melanie Hiller • Washington, DC • Feb 25, 2014 http://www.flickr.com/photos/22526649@N03/12784562863
  95. 95. Lane Hudson, Community Leader, and Ruby Jade Corado, D.C. Humanist-Transgender woman Washington, DC • March 27, 2014 http://www.flickr.com/photos/22526649@N03/13465159024
  96. 96. Marsha P Johnson, 1944-1992, Black Transgender Rights Activist
  97. 97. Sylvia Rae Rivera (1951 – 2002) American bisexual transgender activist and trans woman http://highkixx.com/2012/01/

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