Just Read: Trojan Horses of Race, Unconscious Bias, and Transgender Person Health and Medical Care

Continuing my learning journey in preparation for the Kaiser Permanente 2nd Annual LGBTQI Health Symposium, I felt I needed to get grounded in the theory and science around unconscious bias. It’s fascinating, it’s bizarre, and it’s empowering all at the same time. 

This piece was published in the Harvard Law Review, by Jerry Kang who has since produced a TEDx talk on the subject, see below. The review is exhaustive, I’ll try and break down the feelings below.

The fascinating

The human brain continues to be the most amazing machine ever. It helps us navigate our world by attaching feelings to patterns faster than we can consciously be aware of. These result in our behaviors. The reactions that can now be tested using the Implicit Association Test are visualizable using functional MRI’s. “It’s as if a Trojan Horse virus has hijacked our brains.”

In the case of race, as is reviewed here, the mere image of a Black face during an experiment where a computer crashes repeatedly results in more hostile feelings toward the situation compared to a White face being shown.

Experiment after experiment continue to show that there’s a “dissociation” between what a person consciously thinks with regard to race and how they react, in unconscious ways, or as it is said:

There is no immaculate perception

The behaviors that result from these reactions have been tested, and to pick out the ones that are most relevant to clinical medicine:

  • Nonverbal behaviors – There was “greater speaking time, more smiling, more extemporaneous social comments, fewer speech errors, and fewer speech hesitations in interactions” in situations where there was less measured implicit bias. 
  • Vicious circle – Less friendly non-verbal behavior by an interviewer creates an unfriendly retaliatory response by the interviewee, resulting in overall greater hostility in an interaction

The bizarre

  • Implicit bias can occur against or for one’s own group, and performance on tasks can be activated or depressed by activating certain identities or impressions.
  • Black undergraduate students perform more poorly on an exam when they’re told it’s measuring “ability” 
  • Asian women at Harvard who are primed with questions about Asian identity do better on math exams then Asian women who are not. When this test was repeated in Vancouver, Canada, where there is less measured stereotype around Asian people and math performance, there wasn’t a boost. If non-Asian students were primed with words associated with Asians, they experienced a boost.

The empowering

The total impact of these interactional phenomena on education (admissions, mentoring), employment (hiring, promotion), social networking (friendship, marriage, collegiality), and market transactions (auto purchases, mortgages) cannot be underestimated.

I’ll add clinical medicine to all of that. Like all human beings, health care professionals are conditioned to react in unconscious ways to people who are (a) in a small minority, and therefore “unknown”, such as people who are transgender and (b) exist in a state of perpetual unhealth because the very health system that is supposed to heal them excludes them (see: Now Reading: Care of Transsexual Persons — NEJM, in the era of inclusion | Ted Eytan, MD)

The evidence shows that implicit bias is malleable/changeable through various means, including positive imagery and “exemplar accessibility.” People shown images of Martin Luther King, Jr., have less implicit bias on further testing. Female college students with greater exposure to female faculty had diminished or eliminated implicit bias against women.

Putting this all together (I know, it’s a complicated web):

  • Implicit bias exists, and is separated from how a person outwardly expresses feelings toward a minority group
  • It can affect a minority group’ own perception of itself
  • It can be altered through positive imagery, and in newer studies, imagined positive contact (more on that later)
  • The vicious circle can be turned into a virtuous one

All of this data explains a lot of what I have seen and provides hope. When I encounter a minority group that actually believes it doesn’t deserve to be respected, and a profession and society that responds in kind with disrespect, I see a situation that’s explainable and treatable using social cognitive science.

As more people who are transgender receive medically necessary care, there will be more positive exemplars in our society. That exposure will turnaround reinforced negative biases into positive ones. Greater awareness in the medical profession of the impact of implicit bias will also result in correction, and the vicious circle will turn into a virtuous one. Look at what has been happening for people who are lesbian, gay, or bisexual. We can see the same happening for people who are transgender.

This research creates new vision for what’s happening around us, and explains what I am seeing around me in Washington, DC. Witness the words of Ruby Corado, recently, in speaking of our Mayor:

I have seen this man smile many times when he encountered me and other trans people at events, he smiled when others frowned and were disgusted to see me/us.

Thanks to him, we now don’t have to inject industrial silicone in our bodies that is supposed to be in planes not humans.

Thanks to him We are no longer deemed disposable and seen as less than human and our lives finally have value to many.

Thanks to this man, now people that never acknowledged my work and ignored that I existed for years, embrace me as another community leader.

In some of my work as a trans person ally, I haven’t been sure in some conversations that the people I am talking to actually believe that people who are transgender are human beings, and as Ruby mentions, I now see how this is going to change. To summarize in the language of status updates:

Maybe these beliefs have been true, which is frustrating,

Feeling  38983

Maybe the people who feel this way don’t realize it, which is empowering,

Feeling  38985

..and now we know how we’re going to change all of it, which is determination enhancing.

Feeling  38984

As always glass is 3/4 full, and love always wins.

TEDx Talk from Jerry Kang is below. Enjoy. Comments always welcome.

1 Comment

Ted Eytan, MD