Just Read: #WhatADoctorLooksLike – Implicit Bias in Academic Medicine – via JAMA

Where I went to medical school (University of Arizona College of Medicine), we had the typical “wall of fame” of all the previous graduating classes prominently mounted, covering the history of the school’s first class from 1967 to the present.

It was amusing to note that as you walked along the wall that the number of women in each class steadily increased, to the year after mine, when for the first time there were more women than men in incoming class.

Except that in retrospect, it wasn’t really funny.

The other thing I noticed was that the Nursing School building, erected a few years after the medical school building next to it, didn’t seem to have very many men’s rooms…

The wall showed another thing, that there were no LGBTQ human beings enrolled in this school. Except that there were. However, all the signs and signals in our curriculum and the behavior of our faculty conspired to keep this just an “allegation.”

And so…we can now measure the impact.

This issue of JAMA Internal Medicine includes three studies looking at sex and racial bias in academic medicine, and as it has been shown in many (many) other studies, the profession tends to mirror the society around it. No more, no less. This is a link to the editorial accompanying the studies, written by Molly Cooke, MD (@mollymcooke) at the University of California, San Francisco.

Cooke M, AJM A, RA G, E M, M N-S. Implicit Bias in Academic Medicine. JAMA Intern Med [Internet]. 2017 Mar 6 [cited 2017 Mar 15]; Available from: http://archinte.jamanetwork.com/article.aspx?doi=10.1001/jamainternmed.2016.9643

This wouldn’t be a problem (actually, it would always be a problem, but maybe not as high-stakes) if our society’s health didn’t depend on physicians who understand the life experience of the communities they serve (It does).

Another bank of studies show clearly that people learn better from people who resemble their life experience more closely. It’s just science, not an opinion. And so, when people are selected to present at grand rounds:

To the extent that those role models do not mirror the sex and racial composition of the trainee pool, we are delivering the implicit but powerful message that these leadership roles and examples of excellence are for someone else. Women, blacks, Asians, and Latinos need not apply.

I have previously posted on the environment around LGBTQ trainees, also studied, and also with outcomes that parallel these.

Just Read: Sexual and Gender Minority Identity Disclosure: “In the Closet” in Medical School

This gendered quote from a general practitioner in 1966 (the ancestors of my medical specialty, family medicine) is relevant here:

S/He does more than treat them when they are ill; he is the objective witness of their lives. They seldom refer to him as a witness…that is why I chose the rather humble word clerk: the clerk of their records.

If this is what doctors do (it is), then we have an interest in examining our biases and modulating them. And there’s science to show that can be done, too. Isn’t this century grand 🙂 .

One more from Shania Twain, because it’s my RSS feed.

She’s a geologist, a romance novelist
She is a mother of three
She is a soldier, she is a wife
She is a surgeon, she’ll save your life
She’s, not, just a pretty face
She’s, got, everything it takes

I’ll post again on the actual studies referenced.

Why some people don’t get a thank you for using my photos

Do I really mean thanks when I say thanks?

An esteemed colleague of mine asked me recently,

“When you say ‘thank you’ via social media to someone using your photos, are you truly thanking them?”

The answer is an unequivocal yes!

My photographs are Creative Commons Licensed, and meant to be used to promote the best of the human spirit. I want to give people credit for using the work, and amplify their work at the same time. Here’s an example:

I’ve counted 895 placements so far, and 99.9% of them deserve and receive a thank you.

When is a time I don’t say thanks?

This happens rarely, in cases where my work is used to further un-scientific or unhealthy discourse, especially directed at a group of people. In these cases, that I can count in the single digits over the past several years, I will revoke the license to use the work. Here’s an example of that:

December 21 2016
Ahoy Charisma News!
I see that you’ve used this photo of mine in this post of yours:
http://www.charismanews.com (Direct link removed due to triggering nature of the content)
As it is being used to promote non-scientific and inaccurate health information about #LGBTQ human beings, license to use the photo is revoked. Please remove my photograph from this web page immediately.
I am happy to educate you on the science behind gender at your convenience. Life is good for all humans in the 21st Century, trust me, I’m a doctor :).
All the best for a more informed future for you and the people you humbly serve.
Ted Eytan, MD

In the example above, my work was removed quickly, and another (less interesting) image was put in its place. I appreciated that.

I’m posting this here so that it’s in the ether, and because I may refer people to this post in the future if the license to use my work is revoked. My interest is in the reasoning to be clear and everyone is treated with respect.

Before and with every termination notice, I always offer to educate about why something isn’t factual and not permitted with the use of my work. From this perspective the use of my work offers an opportunity to educate that might not have existed otherwise.

There are a lot of in-between circumstances where license to use is not terminated, and I just leave a comment or add to the conversation in whatever way is appropriate, based on my professional judgement. A Creative Commons license is meant to be used and I respect that as well.

Any questions, feel free to leave them in the comments or contact me via the form above.

You can look at the comments. My experiment in ending transphobia. What you don’t permit, you don’t promote

2016.05.21 Capital TransPride Washington DC USA 0395
The photograph that provided the substrate for the natural experiment: 2016.05.21 Capital TransPride Washington DC USA 0395 (View on Flickr.com)

I’ve written about this topic a few times. Finally I had the opportunity to experience it for myself.

As I regularly do, I monitor the use of my photographs, especially in the context of promoting healthy humans and societies. When they don’t meet that standard, license is revoked. In the in-between situations, I provide education, here’s an example from April, 2016.

And so I did this on this blog post

Comment on publishing my photo, Christianity Today, in “Evangelicals and Transgender Morality”

and also on Facebook – (direct link here and embedded below).

In social media spaces, the challenge of any platform that you don’t control (Facebook) is that there are things out of your control. Given that situation, I carefully judge where and when I engage in what I call health activism.

Knowing this, I still didn’t expect it, but…it happened.

Ever so subtly and then more apparently, transphobic comments began appearing on the post.

Per my policy, I addressed each one, quickly, in the realm of science. The thing is, individually they didn’t seem transphobic, however, as a group there was much greater clarity.

A few things then happened:

  1. I was alerted by my mentor that the comments with responses could trigger people negatively, and so I should put a warning at the top of the post. I learned a new term in this interaction: Trans-Erasure. I did so:

    Addendum (7/16): On request, letting people know about Transphobia/Transerasure in the comments. If this is triggering, please avoid.

  2. I then reflected on the complete body of comments and realized that the ideal of open dialogue and education had long passed.

With that, I put up a separate statement:

Addendum 2 (7/17): Transphobic comments deleted. The interest of showing people how to respond has been well served, its my feed, I’m not obligated to host or promote transphobia anywhere (why I wrote the comment in the first place). I’ve written on my philosophy about this here.

It’s not what you do, it’s what you tolerate. Future comments will be deleted without comment. Bonus, Less paperwork, and the comments flow much better :). If anyone notices any triggering comments, let me know, I’ll take care of them for you right away. Thanks for your support.

I then deleted I all of the transphobic comments, and my replies to them.

And guess what. They stopped. All of them. I made sure that my statement was posted as a comment so that the people involved were notified. And they still stopped. It’s now over a month later and they have not returned. That’s all it took.

Using the Scientific Method: My hypothesis was proven correct.

Ultimately, the topic of gender identity has a scientific basis and I prefer to make discoveries using scientific techniques – creating a hypothesis, testing it, and evaluating the outcome, which is what I did here. Science is the way to go 🙂 .

My hypothesis was correct.

People will create hostile environments directed toward transgender (and all LGBTQ people) when given license. Remove the license, the environments become neutral, and then the environment can be changed to make them healing (which is what we’re here for).

I’m doing a lot of reading about moral license and I’ll post on that in the next few weeks. In the meantime, I’m putting this post up so that

  • I can refer journalists and publishers to it during the times that they inadvertently give people moral license to hurt others.
  • I can archive this experience somewhere where it’s easily referred to. The other thing about social networks is that their archival capabilities are questionable – word to the wise.

What you Permit, You Promote

I have feelings about these situations. Here’s why.

Quint Studer’s (@quint_studer) words have always stuck with me, in so many contexts:

What You Permit, You Promote | Sharing thoughts, ideas and suggestions on hardwiring success

The other words that have stuck with me, in so many contexts are the ones below. The opposite of social networking is social isolation, which is usually the first step in the creation of a lot more damage. When people are conditioned to avoid spaces, social isolation is the result (and the intent of people in these spaces).

When confronted with these situations then, it’s easy to know what to do.

As I discovered in my successful experiment, it’s not that hard to do it. It just needs to be done.

It's not what you do, it's what you tolerate.

A photo posted by Ted Eytan (tedeytan) on

Comment on publishing my photo, Christianity Today, in “Evangelicals and Transgender Morality”

2016.05.21 Capital TransPride Washington DC USA 0395
2016.05.21 Capital TransPride Washington DC USA 0395 (View on Flickr.com)

Good news, the information behind your article is all wrong, moral dilemma averted

Thanks for publishing my photo Christianity Today (@CTMagazine). Since the post doesn’t allow for commenting, I’ll post my comment to the article (Where Evangelicals Stand on Transgender Morality | Gleanings | ChristianityToday.com) here, which is:

Greetings Christianity Today,

Thanks for publishing my photograph of an all gender restroom. I’m a physician based in the world of science and I can offer you some good news based on my reading of your article.

Putting aside your use of inappropriate language to describe this population, the survey you’re describing is flawed and asks the wrong question.

If you’re worried about the morality of “changing gender” then you need not worry, because gender identity is something that doesn’t change in the transition process. What a transgender person is accomplishing through medically supervised hormones and surgical procedure is aligning their gender with its expression and physical characteristics. That’s why it’s called “gender affirmation” or “gender confirmation.” There’s really no such thing as “gender reassignment.”

Understanding then, that a person isn’t changing gender or identifying with a different gender should help you. What a person is really doing is identifying with their gender, and living authentically in that gender thanks to medical support and science. Therefore, the moral conundrum you’re writing about doesn’t seem to exist.

I hope that helps you, feel free to use my photographs in the future to encourage dialogue and support of this community (and the converse, you’re not licensed to use them if you support misinformation or 20th Century thinking).

If this is still confusing to you, let me know and I can provide more education to you and your staff.

Also, please review (and use) the GLAAD style guide designed for journalists so you can use accurate terminology in your writing.

All the best & thanks for the opportunity to comment.

-Ted Eytan, MD

Reading the comments and writing some. Thoughts on ending transphobia

Ending Transphobia examples - Christianity Daily_
Ending Transphobia examples – Christianity Daily_ (View on Flickr.com)
Transgender Bathroom Awareness Poster lgbtplusbristol 50079
This is really the best image to use – Transgender Bathroom Awareness Poster lgbtplusbristol 50079 (View on Flickr.com)

Hello Christianity Daily!

Thanks for publishing my photo. However, you’re accompanying it with an inaccurate, and offensive term, which is considered dehumanizing ( a good primer on this is here http://time.com/3630965/transg… , there’s also a readily available journalistic style guide at GLAAD.org – take a few minutes to read it next time, please).

Please either

1. Replace the terms used above with human terms, e.g. “people who are transgender,” “transgender people”

or if you elect not to do the above,

2. Remove the photo as it violates the license for use as listed on the main photo page because your article accompanies and promotes transphobic sentiments:  https://www.flickr.com/photos/…– sorry that’s not allowed with my photos.

By the way, Flickr community guidelines also require a link back to the photo, so please implement that as well.

You’re of course welcome to use these photos in the interest of telling a story that supports equality, and the latest science.

It’s clear in the 21st Century that gender segregated bathrooms do not confer a safety advantage over gender neutral ones. In fact, in Washington, DC, it’s the law – all single stall bathrooms must be gender neutral. This is because they’re safer, fair (to women and men), and promote the health of all. It’s been like this for several years now, and no one is uncomfortable, more people are safer and can participate in society, as they should.

Isn’t this century great? Please join us :).

Have a great day,

Ted Eytan, MD
Washington, DC USA

“Never read the comments” is what people say about articles online that cover LGBTQ and specifically transgender issues.

What they mean, often correctly, is that the biased and unloving statements they may see will trigger negative feelings and reminders that we live in a world that is still learning to love better.

We shouldn’t have to see those comments, though, because they shouldn’t be allowed in the first place.

It’s the accountability of the publisher to manage this, and plenty of publishers do this just fine, so it’s not an impossible task.  You just have to want to do it. Harvard Business Review is an example of a publication that has figured this out. Read their comment policy.

Publishers that allow untoward comments are contributing to implicit and explicit bias as much as the comment writers are.

Studies show that for most Americans, there are explicit (verablized, written) opinions about certain classes of people that are off limits. For other groups, like LGBTQ people…..

The comments that I encounter that relate to me are of a different kind, in the way a publisher might use a photo I’ve taken to adorn an article.

For as long as I’ve put photos (or mostly anything on the web), I’ve made them open source. I still own the copyright but they are Creative Commons licensed, even for commercial use.

Depending on the issues of the day, some photos get regularly placed in publications. This one has been used a lot:

SCOTUS APRIL 2015 LGBTQ 54663 (View on Flickr.com)

Same with this one.

Celebrating a new America #lovewins 58242
Celebrating a new America #lovewins 58242 (View on Flickr.com)

For obvious reasons (love always wins).

Photos of gender neutral restrooms have also been getting used lately, also for obvious reasons.

Through various internettable means, I review the use of each photo, and 99.9% of the time they’re used to support a conversation that supports the human spirit. As long as they don’t contribute to bias, they’re fine. Some uses are clearly over the line, and for those I request a takedown. I’ve done that less than 5 times over the past 3 years. The rest I tweet/post a thank you and give credit to the publisher.

Then there are the in between times, the time where a teachable moment is possible. For these times I engage and write the comment, and give people the option to use or not use the photo.

I’m posting a recent example that had a good outcome. Replacement of offensive terms with accurate ones, for use of a photo in Christianity Daily. Headline changed, photo taken down (although this was not a requirement of mine, but fine with me), and my comment left on their site.

In another instance (which I won’t link to here), I posted a comment, received a very kind reply (which surprised me, considering the tone of the article), photo taken down, comment removed. Good outcome there as well.

I have control over what I have control over, so this blog doesn’t allow any negative comments directed at people or classes of people. Same goes with the use of any photos I take. I am a publisher, too.


What you permit you promote.

It’s not what you do, it’s what you tolerate.

None of us came to health care hoping to make the world a less loving place, and fortunately the opposite is happening, with our help.

Isn’t this century the best 🙂 .

PS, this photo has been used a lot more than all of the above, and it’s the most accurate. So in the end, the crowd does know the science, and you-know-what wins ( <3 ).

Transgender Bathroom Awareness Poster lgbtplusbristol 50079
Transgender Bathroom Awareness Poster lgbtplusbristol 50079 (View on Flickr.com)

this post adapted from a facebook post – putting it here so it says in the ether somewhere

The comments are respectful, too, in Changing Gender on the Job – Harvard Business Review

Crucible: Changing Gender on the Job – Harvard Business Review.

Thanks to twitter friend James Spicka (@jcs0716) for pointing this article out to me, it describes the experience of Michael Wallent becoming Megan Wallent at Microsoft Corporation, as published in the Harvard Business Review (@HarvardBiz).

It isn’t just the article that impressed me, it’s the comments. While doing research on transgender health, I have found that most news/media outlets find it perfectly acceptable to publish hateful and prejudicial comments directed at this population, even when they are flagged by other readers. I have found this contributes to the feeling I see in members of this group of people of being invisible or not deserving of compassion. It’s not healthy.

And then there’s the Harvard Business Review, that curates a rational discussion and even apologizes for confusion it creates in labeling of Megan. It shows that people are in fact capable of being respectful and supportive – if this is the expectation. As Quinton Studer once said (I think it was him) – “What you permit, you promote.”

This is the expectation I have and I am really blown away and also unsurprised at the same time at how many people have come to me with articles, ideas, things they see, and messages of support for this and the entire LGBT community. The human spirit is predictably awesome :).

And, Megan is now Michael again

A trip to MeganWallent.com reveals that Megan is transitioning back to Michael. The blog post, News, is definitely worth a read.

Michael’s rationale makes sense, and it tells me that a person who is transgender is a person – unique and deserving of respect. Health care professionals are here to provide care, dignity, respect for every person, it’s what we do and what we went to school for. Expect it, we’ll deliver it. Our generation enjoys practicing the medicine of inclusion.