Photo Friday: 2014 International Transgender Day of Remembrance, Washington, DC USA

The Transgender Day of Remembrance serves several purposes. It raises public awareness of hate crimes against transgender people, an action that current media doesn’t perform. Day of Remembrance publicly mourns and honors the lives of our brothers and sisters who might otherwise be forgotten. Through the vigil, we express love and respect for our people in the face of national indifference and hatred. Day of Remembrance reminds non-transgender people that we are their sons, daughters, parents, friends and lovers. Day of Remembrance gives our allies a chance to step forward with us and stand in vigil, memorializing those of us who’ve died by anti-transgender violence.

DC is surrounded by angels today, angels who never had a chance to say goodbye to many of us but thru their unique lives and loved shared while they were here, live in our hearts everyday.At Casa Ruby, 7 Trans women(mostly women of color) and many volunteers, honor their lives everyday by taking care of those who are still here, the young Transgenders who are homeless, the sex workers that are looking for a job, the elderly who want to be in a family setting, We all come together 6 days a week to make all of our lives a little better in a place we call HOME. – Ruby Corado (@CasaRubyDC)

Health care has an important role to play, not just in providing the necessary medicines and care so that people can achieve their life goals, also as allies, changing our society to normalize all forms of gender expression. Once upon a time, all LGBTQ people were forgotten by society. Now it is great to be present with community leaders and Metropolitan Police Department, and celebrate new opportunities for the LGBTQ community to live.

Friends & Family, It’s A Reality!! We Will Be Opening Casa Ruby Homeless LGBT Youth House. Today, I Embark on one of the biggest challenges of my life, Opening a 12 Bed Fully Equipped Home For LGBT Homeless Youth In Washington, DC. – Ruby Corado (@CasaRubyDC)

Statement from the White House on International Transgender Day of Remembrance.

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Just Read: A perfect score for Kaiser Permanente on the Human Rights Campaign Corporate Equality Index again for 2015

One-third of the Fortune 500 and over half of the CEI universe of businesses offer transgender-inclusive health care coverage, up from 0 in 2002 and nearly ten times as many businesses as five years ago;

Kaiser Permanente is one of them, of course, and every doctor should be part of a health system that is also. One day they will be.

Having 100% on the Corporate Equality Index doesn’t guarantee freedom from bias; it creates a beacon/example for other organizations and people. It’s important to remember that in the majority of States of the United States (29), you can be fired from your job simply because you are gay, lesbian, bisexual, or transgender. This is only one less state than last year. (see: A perfect score on the Human Rights Campaign Corporate Equality Index again for 2014 | Ted Eytan, MD)

This year, Kaiser Permanente is 1 of just 366 companies who earned 100%. Last year, it was one of 303. As I mentioned two years ago (see: What it means to earn a perfect score on the Human Rights Campaign Corporate Equality Index | Ted Eytan, MD):

There are a lot of other companies in this year’s index that earned a 100% score, and there were a lot that earned a 0% score.

Being 100% in terms of providing equal opportunity within the workplace and demonstrating support in the community for all is where I’d like to be, because Equality equals Health.

Thanks to the team in Kaiser Permanente’s National Diversity and Inclusion organization who do so much to promote health through their work.

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Just Read: Just 6 more seconds of listening needed to elicit the patient’s agenda

“…asking “Anything else?” repeatedly until a complete agenda has been identified appears to take 6 seconds longer than interviews in which the patient’s agenda is interrupted” Reference: Marvel MK, Epstein RM, Flowers K, Beckman HB. Soliciting the Patient’s Agenda: Have We Improved? Jama. 1999;281(3):283–287

Actually I read this a while ago; I realize I’ve never turned it into a slide, until now.

I’m using it to illustrate an artifact of physician culture, part of a keynote I’m preparing (Crowdsource Request: Keynote for Labor-Management Parntership all-hands – “Social innovation” | Ted Eytan, MD).

We tend to interrupt people. On average about 23 seconds into them telling us why they are here to see us. Good news is that it improved 5 seconds in between the 15 years it was studied (1984 and 1999). I can’t find a newer study, if anyone knows of one, let me know.

Interestingly, it was found that if physicians just listened for 6 seconds longer, by repeatedly asking “Anything else?” or “Tell me more?” they were able to know what the patient was concerned about. The opposite of this is not knowing up front, and the consequences of that – the door handle conversation, the “late concern,” the problem unexplored, and a less efficient encounter, and sometimes devastating health experience.

One interesting correlation is that physicians with fellowship training (training after residency) were more likely to exhibit listening behavior than those who didn’t have the training. These were all family medicine specialists so there’s no comparison of other specialties in this study.

This fits with what I have mentioned before in the world of listening, reducing conscious and unconscious bias, being there for the people we serve in and out of the exam room. The good news is it’s easy to move away from a “Yes I know what you’re asking for,” culture to a “tell me more” culture. I know because I do it all the time – “say more.” My colleague Danielle Cass (@DanielleCass) also taught me this one – “Go on..” Try replacing this response with the one you normally use and see what happens (and let me know what happens – magical!).

Listening is the hugest innovation in health in the decade of the patient.

6 seconds :)

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Innovation often happens in out of the way places

…. when using human centered design.

Arli Christian (see staff bios here), from the National Center for Transgender Equality (@TransEquality), is joining the sponsor group for Project Lantern, which will explore the transgender person life and health experience using a human centered design approach, led by the Kaiser Permanente Innovation Consultancy (@KPInnovation) – Photograph taken in Washington, DC USA

With Chris McCarthy (left), Ted Eytan (center)

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Just Read: State of Transgender Person Health, the dawn of primary care in Colorado

This is a new report published by One Colorado (@One_Colorado) that’s a non-randomized survey of 417 transgender and gender nonconforming Colorado residents. Even though it’s not randomized, that’s a pretty large sample size for this population. A few findings that caught my eye:

Survey participants reported being much more likely to have a college degree, yet were more likely to be out of work or living in a low-income household than the general population, leading to shocking income inequality for transgender Coloradans.

The Dawn of Primary Care for People who are Transgender

In the health space I noticed some metrics about the impact of having regular primary care that’s inclusive (which 61% of respondents report, contrasting to 88% of physicians who reported comfort in a previous survey):

Impact of having an inclusive provider on mental health

The data regarding mental health for this population tracks what I have seen in previous surveys in terms of high suicide rate attempt – Just Read: The exceptionally higher suicide attempt rate for trans* persons who have sought medical care | Ted Eytan, MD – although the questions in this survey and the one before it are slightly different. It isn’t known for sure what aspects of medical care may improve mental health, it’s just known that there are significant problems that are not being addressed.

The “dawn of primary care” part is the fact that access to medical care is now being measured, and is measurable, because of Colorado’s leading position in assuring medically necessary care for the LGBT community, much like Washington, DC (have to put in a plug for the #epicenter).

The Colorado Independent (@coindependent) story on this report mentions the example of a patient who know has regular (and comprehensive medical) primary care through… Kaiser Permanente Colorado (@KPColorado), where it denied at the VA (see: Thanks for publishing my photo and a bright spot in transgender person health, Colorado Independent | Ted Eytan, MD)

The second part is the fact that with regular primary care, a lot more appropriate medical care for total health will be administered, so “transgender person health care” will just be “health care.” For example, conventional wisdom is that every transgender man should have a hysterectomy, because it is unlikely that they will receive regular cervical cancer screening, because of a host of factors. This is partially based on inadequate access to care and inappropriate treatment in the health care system, and may change.

As more people are able to live, there are more people who they’ll know / Gallup – behind the times….

Gallup has been tracking this question for 30 years:

Do you have any friends or relatives or coworkers who have told you, personally that they are gay or lesbian?

As predicted, the numbers have flipped, the the majority of Americans currently “do.” (See this nice graph over at The Economist)

The Gallup (@Gallup) behind the times part is that the question excludes people who are transgender, and I’d argue, most of Gallup’s site does – the heading of this section is “same-sex relations” and the URL is “gay-lesbian rights”, where’s the rest of LGBT?

Even though we don’t have the data today (I hope we’ll start collecting it), it’s likely that we’ll see a same trend in terms of knowing someone who is transgender. This will be accelerated by access to medical care because more people will get to live in their identity, in good health, with employment, and the rest will be history….

I did a quick look and I actually can’t find a poll question anywhere that asks “Do you currently know someone who is transgender?” – if anyone out there knows of one please contact me or add a comment, thank you! And thanks One Colorado for documenting the state of health and its future improvement.

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Thanks for publishing my photo and a bright spot in transgender person health, Colorado Independent

Today, Winners is employed as an engineer and has health insurance through Kaiser Permanente (Colorado).

The insurer gives transgender clients a list of preferred providers trained in transgender-specific care.“The biggest change is actually having a primary care physician that’s not only educated about transgender health care but passionate about advocating for transgender people,” Winners said.Winners’s latest health care experience is indicative of major ground won by transgender people and their advocates. Even so, her previous experience of exclusion still persists for many in the transgender community.

Thank you, Colorado Independent (@coindependent) and Tessa Cheek (@TessaCheek) for highlighting challenges in transgender person health as outlined in the new One Colorado Report “Transparent” (separate post coming on that), AND an example where a change in approach is happening, as described above. Congratulations, Kaiser Permanente Colorado (@KPColorado) in being a leader. I am familiar with their work and it’s impressive.

Here’s the rest of the story, published verbatim, because The Colorado Independent allows republishing of their content, just like I do. I really like the 21st Century, don’t you? :)

Thanks for publishing my photo for this story, taken in Washington, DC, March, 2013 – View on

Link to the original: Report: Transgender Coloradans still struggle to receieve adequate health care | The Colorado Independent, and

Thanks for publishing my photograph to illustrate the story. It was taken in another 21st Century Place, Washington, DC, USA, where people believe anything is possible, because it is.

A lot has changed for Kallie Winners since she first sought medical treatment to begin her male-to-female transition in 2011. Winners, who spent 10 years in the military, initially visited Denver’s VA Medical Center where she quickly discovered doctors had not been trained to treat transgender patients. She was ultimately denied care.

“It’s hard to describe to somebody who’s not transgender what it’s like to live your entire life in a body you don’t recognize,” she said. “To go to the place where I felt I could get care, which was the VA, and to be denied was awful. It was so awful, I didn’t step foot in a VA for the next three years.”

Even though she was finishing college, Winners ended up paying for her transition out of pocket at an average annual cost of $1,800.

Today, Winners is employed as an engineer and has health insurance through Kaiser Permanente. The insurer gives transgender clients a list of preferred providers trained in transgender-specific care.

“The biggest change is actually having a primary care physician that’s not only educated about transgender health care but passionate about advocating for transgender people,” Winners said.

Winners’s latest health care experience is indicative of major ground won by transgender people and their advocates. Even so, her previous experience of exclusion still persists for many in the transgender community.

A new report from LGBTQ rights organization One Colorado entitled Transparent sheds light on the successes and challenges transgender Coloradans have found in the rapidly evolving health care system. The passage of the Affordable Care Act (ACA or Obamacare) and Colorado’s decision to expand Medicaid led to some of the more radical changes in accessibility.

“The ACA includes gender identity in its nondiscrimination clause,” said Leo Kattari, the Health Policy Manager at One Colorado, noting that state statute makes a similar prohibition.

“At the state level, it gave those of us in Colorado the opportunity to work with the Division of Insurance to release a bulletin saying that exclusions in health care policies targeted to transgender people is discrimination.”

Since March 2013, when bulletin B-4.49 was released, Kattari says transgender patients can no longer be denied care or asked to pay more for it than everyone else. 

“Testosterone, for example, was covered for a cis man. But a person who is female to male would go to a doctor for a testosterone prescription and get denied. That’s blatant discrimination,” said Kattari.

Though Colorado is one of just seven states with similar protections for transgender patients, it’s one of 27 states, plus Washington D.C., to expand Medicaid.

Kattari noted that the expansion has lead to an 8 percent jump in the number of transgender Coloradans with health care through Medicaid since 2011.

“That’s a huge jump,” Kattari said. “But income disparity is part of why a lot of folks now qualify for Medicaid.”

Indeed while the new One Colorado report indicates that the overall number of transgender Coloradans with healthcare has jumped from 73 percent to 86 percent since 2011, far fewer of them receive benefits through their employer than cis Coloradans. In fact, transgender people are more than twice as likely to rely on Medicaid, in large part due to astonishing income and employment gaps:

Screen Shot 2014-11-13 at 1.17.06 PMScreen Shot 2014-11-13 at 1.17.15 PM


As a result, though coverage has improved, transgender Coloradans are still uninsured at higher rates than the general population (14 percent to 11 percent) and 40 percent still say cost is their primary barrier to accessing care.

Perhaps unsurprisingly, given the history of structural exclusion in health care, just under a third of transgender Coloradans say fear of discrimination is the second-biggest barrier to their accessing care. Kattari notes that discrimination against transgender people is hardly limited to the doctor’s office but extends into the everyday, from navigating social norms surrounding gender presentation and public bathroom use to being routinely addressed with the wrong pronoun. The net effect of exclusion from care and often daily discrimination paints a troubling picture of mental health for those in Colorado’s transgender community.

Screen Shot 2014-11-13 at 2.43.14 PM

“These high levels of depression and anxiety are not because folks are transgender, but because of repeated experiences of prejudice and stigma,” said Kattari. “It’s hard to find a doctor who knows to ask for your preferred name and pronoun or is willing to prescribe hormones. To get access to a provider you trust is hard.”

One Colorado did find that having an inclusive provider was a serious indicator of better mental health among transgender people, though it didn’t bring patients mental health totally in line with the general population. For example, transgender people with an inclusive provider were half as likely to have attempted suicide in the past year, but still seven times more likely to have attempted than the general population.

“Until the medical community understands who transgender people are and has studied the data on the health disparities they face, transgender Coloradans’ health care needs will never truly be addressed,” Kattari concluded in the report’s release. “We have worked hard to begin tackling the barriers that transgender Coloradans face in our health systems, but there is much more work to do to ensure that all of us are receiving the care and the coverage we deserve.”


[Graphics from the Transparent report. Lead photo by Ted Eytan

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Photo Friday: Paying Ourselves the Highest Tribute, Washington, DC USA #SocialInnovation

“In recognizing the humanity of our fellow beings, we pay ourselves the highest tribute.”

Washington, DC is full of monuments, in out of the way places, to the people who were the most prolific social innovators. I love discovering all of them. This series is from the Thurgood Marshall Center and the African American Civil War Museum, (@AfroAmCivilWar) which happened to be open on a day it wasn’t supposed to be.

The Twelfth Street YMCA Building, constructed 1908-1912, was the home of the first-full service YMCA in the nation to serve African Americans, including the site where Thurgood Marshall mentored young men and authored portions of the Brown vs. the Board of Education. The YWCA was conceived by a former slave Anthony Bowen; Booker T. Washington’s son-in-law served as architect; and President Teddy Roosevelt laid the first cornerstone. Today, Cecilia S. Marshall, Justice Marshall’s wife, serves as the Honorary Chair of the Thurgood Marshall Center Trust, Inc. (TMCT’s) Board of Directors. TMCT, the proprietors of the historic Thurgood Marshall Center for Services and Heritage is a non-profit organization dedicated to facilitating social services to the needy.

Some of the photos below are jarring, as are the conversations around them. A great quote that helps:

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.

There’s a ton of social innovation that’s happening here now, in our capital city, in out of the way places, except not a lot of people know about it … yet. But they will, name your health issue. Thanks to all the (s)heroes, past, present, and future who are creating a better world for all human beings :).

“History isn’t something you look back at and say it was inevitable……it happens because people make decisions that are sometimes very impulsive and of the moment, but those moments are cumulative realities…”( “History isn’t something you look back at and say it was inevitable” : Life and Times of Marsha P Johnson | Ted Eytan, MD)

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