Good morning, everyone. I've never felt so tall. Thank you for coming to our presentation entitled Microaggressions in South Asian Americans, Mental Health Consequences, and Community Strategies. I'm Ronna Parekh, and I have the privilege of opening the session today. Before I introduce my co-chair and panelist, I wanted to share with you a little bit about how this came about, which is in some ways an example of a strategy. Dr. Ranga Ram is the immediate past president of the Indo-American Psychiatric Association, and he enlisted me to help mentor the next generation of Indo-American leaders. To that end, he encouraged me to invite some of the younger generation IAPA members to do an abstract with me. As a much-added bonus, Dr. Ranga Ram was also very interested in the next generation to be very focused on social justice issues and diversity, equity, inclusion, and belonging, which is so much in the lane of medicine today, which is very different than my experiences starting off in medicine. So I am really delighted to be able to present to you the stars of today, this young generation who will definitely be leading our profession, and we're so lucky for it. They've put their heart and soul into this, and it's been such a pleasure to work with them. I'm going to present them in order of appearance. We'll start with Dr. Manan Shah, who is a board-certified general and child and adolescent psychiatrist who completed his training at the University of Virginia. He is currently medical director of the Child and Adolescent Partial Hospitalization Program at Shepard Pratt in Maryland. He also serves on the executive council of the Indo-American Psychiatric Association. And the CEO of Shepard Pratt, Dr. Hirsh Trivedi, is here, so a great example of sponsorship supporting sort of the next generation. Manan, you want to wave so people know who you are? Great. The second presenter today is Dr. Karuna Poddar, who is an international medical graduate and early career psychiatrist. She serves as an assistant professor at Thomas Jefferson University Hospital. She's an active member of so many organizations, including the American Psychiatric Association, the American Association of Child and Adolescent Psychiatry, and regional chapters as well, including also the Indo-American Psychiatric Association. Her work focuses on providing culturally competent care, quality improvement, and patient safety. Karuna, do you want to wave? Great. And then our final presenter, and then I'll talk about my co-chair, is Dr. Dhruv Gupta, who completed his undergraduate and graduate education at Tulane University in New Orleans after attending medical school in England. He's currently a fourth year psychiatry resident at ICANN School of Medicine at Mount Sinai Elmhurst Hospital, where he also serves as a senior chief resident. He is an APA diversity fellow and an RFM member on the APA Council on Psychiatry and Law, and he also serves on the APA Presidential Task Force on Structural Racism. He'll be pursuing a fellowship training in forensic psychiatry at the University of Pennsylvania. And Dhruv, do you want to wave? Great. And then finally, my colleague, who I invited to join this scientific session, even though he wasn't on the original abstract. You'll be very clear why we invited him. He has co-mentored with me, and I really am delighted that Dr. Viswanathan is also here as a co-chair. He's a full professor and interim chair of psychiatry at the State University of New York Downstate Health Sciences University. Get ready for this. He's board certified in internal medicine, psychiatry, consultation liaison psychiatry, geriatric psychiatry, addiction psychiatry, and forensic psychiatry. The only thing we're missing, and I won't take umbrage to this, is child and adolescent psychiatry. I'm a child and adolescent psychiatrist. Dr. Viswanathan is a recipient of a SUNY Chancellor Award for Faculty Service Excellence and the very prestigious APA George Tarjan Award for outstanding contributions from an international medical graduate at APA. He has served several, several leadership roles at the APA, and I'll just give you a couple of highlights that are relevant to today's talk. He was the representative to the APA Assembly for Asian American Caucus, the MUR, and he was also an MUR trustee at the APA. Just a couple of slides, and then we'll get started. Just a couple of disclosures. Drs. Gupta, Poddar, and Shah and I have no conflicts to report. Dr. Viswanathan has stock ownership in Moderna and Illumina. Our fourfold objectives today are to first review the Asian American hate, prejudice, and microaggressions literature, and unfortunately there's been more of that, and fortunately we have more and more literature showing that. Dr. Shah will go through that, followed by Dr. Poddar, who will talk about the various forms of microaggressions, including the work of Dr. Gerald Wayne Hsu, looking at microinsults, microassaults, and microinvalidations experienced by South Asian populations living in the United States. From there, Dr. Gupta will talk about the health and mental health consequences of microaggressions, and that I think really has cemented talks like this in grand rounds and multiple medical conferences throughout the country. And then finally, we'd love to engage all of you in the audience around effective strategies for South Asian communities to overcome prejudice, as well as organizational, systemic, and APA strategies so that we can all learn together. Our agenda for today will begin with a very brief, I think powerful, interactive exercise with Dr. Poddar, and then I come back just a little bit to talk about the historical origins of microaggressions as a way of sort of level setting in terms of definitions. From there, we'll talk about anti-Asian hate discrimination, microaggressions, and then sort of the unique nuances faced by South Asian Americans with regards to their type of microaggressions, and then go into the literature around mental health and health consequences. Dr. Viswanathan will take us through a high-level conversation around related topics to microaggressions, and then hopefully we'll have ample time for discussion. And we're going to call on some people in the audience, because we know there's a lot of intellectual wealth and experience, and we want this to be a robust discussion. Thank you all again for coming, and I'm going to hand it off to you, Dr. Poddar. Thank you, Dr. Pari, for that introduction. We are really grateful that we are celebrating the Asian American Pacific Islander Heritage Month this month of May 2022, and I'm grateful to APA that we've got a chance to present on a really upcoming topic in the South Asian community. I'm going to start with a brief exercise, and displayed are the names of some people from the South Asian community. And here I want to invite some of our audience to kindly volunteer to come to the mic, and if you can, just pronounce some of these names for us. Please lightly introduce yourself when you get a chance. Any volunteers? Hi, my name is Sachin Mehta. I'll go with, you know, probably start with where he left off. Number four, Narendra Modi. Number five, Ranil Vikramasinghe. Shahbaz Sharif. Sheikh Hasina. Sher Bahadur Dioba. Thank you, thank you so much. Thank you, appreciate that. I really appreciate you participating in this exercise. Displayed are actually the names of, you know, the leaders of the South Asian community and the country. We have from Afghanistan, Maldives, Bhutan, India, Sri Lanka, Pakistan, Bangladesh, and Nepal. These are the eight South Asian communities, and today our presentation is going to be for people who have originated from these eight South Asian communities. I really request Dr. Parikh to come and introduce us to the topic of microaggression. Thank you so much for your participation. I really appreciate that. Thank you, Dr. Poddar. And what a great exercise on so many levels. It introduces us to the countries of origin for the South Asian community in the United States, but also I think a big theme that a lot of us experience is a mispronunciation of our names. So I really appreciate that and the audience participation. So I'm going to talk a little bit about the historical origins of microaggressions. People who know me know that I was mentored and taught by the great, late Dr. Chester Pierce. I met him when I was a resident in Boston, and then he and I built a center for diversity together in the Department of Psychiatry at the Massachusetts General Hospital. And before I even read anything about microaggressions, I learned about microaggressions firsthand through him. And it's so amazing now to see so many people really embrace this work. When I worked for the American Psychiatric Association, Dr. Saul Levin, the CEO, who is an openly gay man, said to me that when he heard this definition and understood the impact, all of a sudden he had a sense of relief that he knew what had been happening to him. So I think this term has brought a lot of healing, understanding, and also some hope in terms of strategies for folks. So Dr. Pierce wanted a way of describing the ongoing experiences of African Americans post-civil rights movement in the Jim Crow era. He'd been thinking about this idea in the 40s and 50s and really sort of cemented the term and wrote about it in 1969. There's a seminal article by him right around 1969 where he thought about calling it minor offenses, but ultimately landed with the term microaggression. He described a microaggression as being, quote, subtle, stunning, often automatic, and nonverbal exchanges. He was very clear and true to being a psychiatrist that this was from the experience of the recipient or target. Some people use the word victim, but for the purposes of this talk, we'll say recipient and target. The experience was so subtle that perpetrators didn't many times realize something had happened or that they had been aggressors, that it was yet so stunning. So despite being subtle, it was stunning for the recipient and target. Often automatic implied that most of these microaggression experiences were unintentional. And then we know that most language, 87%, is mostly nonverbal. Dr. Pierce went on to describe the fact that African Americans were more likely to experience microaggression several times each day of their life, and hence they were at risk of a cumulative burden of microaggressions which could contribute to physical and mental health consequences, and particularly flattening of self-confidence. My colleagues in the room who are child psychiatrists like me know how hard it is to treat lack of self-confidence. Dr. Pierce went on to describe a microaggression as taking somebody's time, space, energy, and mobility, and this was a big part of his research, that for a recipient or a target or a victim of a microaggression, they spend enormous amount of time in their mind replaying what happened to them, taking away their mental time, their mental space, and their mental energy, preventing them from reading or doing other things that other folks who are not at risk of microaggressions do. Today, the term has evolved to include all minoritized groups or wherever somebody is the other and can include verbal exchanges as well. And with that, I'm going to pass it on to Dr. Shah. Thank you so much, Dr. Parekh and Dr. Poddar. Good morning, everyone. I'm Manan Shah, and I'm going to be talking a little bit more about anti-Asian hate, discrimination, and microaggressions. So to start off, I'd like to review some Asian demographics. So the term Asian American tends to be an umbrella term, which actually constitutes of at least 30 or more culturally distinct groups from at least 20 different countries in East Asia, Southeast Asia, and the Indian subcontinent. Asian Americans have grown nearly three times in the past three decades in this country and is the fastest growing racial or ethnic group in the United States currently. Asians are now in the nation's fourth largest racial and ethnic groups and constitute 7% of the U.S. population. This is a nice map from a New York Times article from last year showing how the Asian share of population in each county has grown over the last three decades. As you can see, in the 90s, it was primarily concentrated on the West Coast, but it has in the next three decades has gone on to also increase on not just the East Coast, but the Midwest, the South, and many other regions of the country. It's my turn to now engage the audience and see if I can get some volunteers for a brief thought exercise. So imagine that you and your entire family have had to leave your home, whether you like it or not. You've been asked to take only two suitcases of your belongings. You have to sell all your other possessions for a fraction of their cost. Strangers are nosing around your house trying to profit from your possessions. You've been herded off to live in horse stables far away from everything that you've known, thousands of miles away, living in communal barracks with hundreds of people with no space or privacy. No one can tell, no one can say how long you're going to be there. You have no sure way of how you're going to endure this. There's no police, no lawyers, no judge. You're not entitled to any due process, any trials. Whether or not you're a citizen of the United States, your main offense is that you're a member of a particular racial or ethnic group. Imagine for a moment, how is this going to make you feel? How is it going to impact you and your family? How would it impact your, most importantly, your physical health, your mental health, your family functioning? How would you feel? What would you do in this situation? How would you react? So this has actually happened. This is a story of Japanese Americans from the 40s and 50s right after Pearl Harbor, where it happened to more than 120,000 Japanese Americans where they were sent off to internment camps just because they were of Japanese origin and had no other fault. Although this is not a modern example or an example of microaggression, this is overt discrimination. This just serves to go over the attitudes towards Asians and to talk about its historical context. On the next slide, we'll go over a little bit more about the historical context. So dating back to the 1800s, Chinese immigrants were first entering the workforce. And they were termed as the yellow peril because they were willing to work for lesser wages at that time. There was a Chinese massacre in 1871 in California. And then in 1854, there was a case, People versus Hall, which was a landmark case where Asian persons were not allowed to testify against a white person. In 1882, the Chinese Exclusion Act further barred the entry of Chinese immigrants into the country. In 1900, the first plague outbreak was also blamed on Chinese Americans in California. 1917, the First Immigration Act further restricted immigration of not just Chinese Americans but other Asian immigrants into the country. At that point, the Chinese immigrants' population dwindled and Japanese Americans started being available into the workforce. And then we saw how in 1942, the previous example, how they were interned off as a consequence of Pearl Harbor. In 1965, the new Immigration and Nationality Act served to finally start accepting immigrants into the country, immigrants that had more of a merit-based reason to immigrate. And skilled laborers started immigrating into the United States at that point. In 1966, pictured here on the right is a original article from New York Times which talked about how Japanese Americans have been the ultimate success story, that they have faced a lot of issues but have still come out successful. And for them to serve as an example community, the term model minority was first used to describe Japanese Americans. This term has gone on to then include many other Asian American communities. Now, although the intention might have been to showcase the success and showcase how the immigrant community, Asian immigrants have been, have set model behaviors and have done so well for themselves, we will look later in the talk as to how this actually has served to cause more psychological harm than anything else, and is now termed as a model minority myth. Moving forward to the current times, the post 9-11, in the post 9-11 world and in the 2000s, South Asian immigrants started being targeted more, also Middle Eastern Americans or Western Asians, the rise of Islamophobia, also not mentioned here, but the Sikh community has been targeted probably because of their clothing, and also the 2003 SARS outbreak started to cause more anti-Asian incidents that started coming forth in the media. We'll be looking at some Asian disparities. So, like we saw in one of the earlier slides, the term Asian American can be a very blanket term, and it actually includes many heterogeneous subgroups that come from different countries and ethnicities, and they may have very different socioeconomic backgrounds, very different health risk factors and outcomes, but oftentimes the health data that is available on Asian Americans tends to be lumped into one category, which is AAPI, or Asian American and Pacific Islander. Lately now, there has been more push in the literature to use the term ethnicity instead of race, so that the data can be disaggregated based on the ethnicities in the countries, because, for example, if you look at ischemic heart disease or cardiovascular conditions in Asian Americans, the prevalence rate, and also cardiovascular death, for example, the prevalence rate tends to match the same rate as in white Americans, but if you disaggregate the data, then there's a very high rate of cardiovascular death in Indian Americans and Filipino Americans. If you look at smoking rates in Asian Americans, smoking rates are lesser in Asian Americans, but if you disaggregate the data, Korean Americans actually have a very high smoking rate. So, why is this important? This is important because we have now disaggregation of data happening in physical conditions, but in mental health conditions, which could be a consequence of the discrimination and microaggressions faced by them, there is still a lot more research that needs to be done in this space, and we're looking forward to having more data. Dr. Gupta will be reviewing some studies specifically related to physical and mental health consequences in the studies that we do have currently. Looking at discrimination faced by Asian Americans across multiple settings, there was a 2017 survey study done which showed that nearly a fourth of the survey respondents experienced discrimination in employment settings. They experienced discrimination in settings where they tried to obtain housing. Nearly a third of the respondents reported facing microaggressions, and a similar amount of people reported facing racial slurs, which also, as we saw now, can be included in the category of microaggressions. Most importantly, however, if you look at healthcare settings, people have also reported discrimination in healthcare settings, and from that particular study, it wasn't clear if this was among healthcare workers or patients or probably both, but it's really important for all of us to recognize that we have been seeing microaggressions in healthcare settings, and we need to be more attuned to recognize these microaggressions happening in our day-to-day settings that we work in, in our clinics, hospitals, and our community health centers, because if we miss this opportunity to recognize them, then we're missing an opportunity to really make an impact. Also, if there are microaggressions happening within healthcare teams, we know that morale and teamwork, even in healthcare, like in other settings, is so important for patient outcomes. So if the morale is going to be low inside a healthcare team because of this, it is going to have an impact on healthcare outcomes. Also, we know that microaggressions have also caused people to actually avoid seeking healthcare because of a fear of discrimination. So ultimately, this is a really important issue here because we're talking about people's lives here, so it's really important to recognize this moving forward. Looking at how COVID-19 has unmasked anti-Asian hate and microaggressions. Not just the virus, but hate speech also has unfortunately spread virally during the pandemic. Derogatory language used in media reports, statements made by politicians, unfortunately racist hashtags trending on social media, statements made by people in a lot of power and authority, like terms used by them, like the Chinese virus, Kung flu, the Wuhan virus. All of these things have normalized anti-Asian xenophobia. As we saw historically, anti-Asian sentiments already existed, and these things have further brought the xenophobia more on the surface and given rise to major incidents. Another issue is wearing of face masks, which often has a very different connotation in the West compared to the East. In the Eastern countries, wearing a mask tends to be viewed more as a way of extending courtesy to your fellow community members. But in our country, face masks have a different historical context. And because of that, that has also been a trigger causing a rise in anti-Asian incidents. A 2020 public poll revealed that a third of Americans actually blamed the Chinese for the virus or the pandemic, and a third of Americans and 60% of Asian Americans have witnessed blaming of Asian immigrants for the pandemic. And when I was looking at the data, these numbers were really staggering to me and very surprising that hate crimes against Asians have increased by 150% in 2020 and 339% in 2021. Now, COVID-19 has also impacted South Asian communities specifically. South Asian immigrants a lot of times have tend to face vulnerabilities because of their immigration status, whether it be a refugee status or whether they're undocumented or because of certain work visas. For example, in my case, I know myself and a few of other colleagues of mine who faced difficulties with not being able to go back to our families and see them because of immigration issues. And to add to that stress, if there are microaggressions happening, it can certainly magnify the effects. Another example, and this would be microaggressions on a more macro level, is when you look at COVID-19 cases and you look at the data, a lot of times hospitalizations, number of cases, number of deaths have been counted as other Asian or unknown instead of specifically categorizing them by country of origin or ethnicity. And that has caused delays in receiving timely and culturally appropriate care and resources. Now, an example of a community strategy here is that many community organizations have stepped up and have taken it upon themselves to translate into appropriate languages to translate the literature available for government resources, for example. Now, with the recent rise in anti-Asian sentiments, as we talked about earlier, there have been some very high profile unfortunate incidents that have come forward in the media. In 2012, the shooting at the Sikh temple in Wisconsin, more recent 2021 Indianapolis FedEx shooting, the Atlanta spa shootings. As we talk right now, there have been more recent incidents, for example, the attack on the Korean women recently, Korean American women in Dallas, Texas, just last week. So the point here is that toxicity clusters in society. When you have a lot of these high profile incidents coming to the media, we can only imagine what is happening in society on a subterranean level. There might be so many microaggressions being faced by South Asians and other Asian communities on a day-to-day basis. And if we don't talk about this, if we don't spread awareness and education, then we're really missing an opportunity to make a difference. Now, an organization called SALT, or South Asian Americans Leading Together, has been a pivotal organization in tracking hate crimes against Asians since 2015. And they've been working with allies for affirmative action to combat COVID-19 related hate crimes. And a new organization called Stop Asian, or Stop AAPI Hate, AAPI again standing for Asian Americans and Pacific Islanders, actually was formed in California in March of 2020. And they have specifically accumulated data about the anti-Asian incidents during the pandemic. And in a few minutes, we'll be reviewing that data. And then there's also been a major community movement called the Stop Asian Hate Movement, which started in March 2021. And we've seen numerous large scale protests in major cities across the United States in the last year. And this movement is going strong. Looking at some of the data from Stop AAPI Hate National Report, there have been a total of 10,905 incidents recorded from March 2020 to December 2021. A majority of these incidents have been verbal harassment, 67% of incidents. And then there's also been physical assault, online cyber bullying. But there's also many types of discrimination faced, which falls under the microaggression category, for example, avoidance or shunning of people, denial of service. So a lot of these incidents have been reported and it's really important to note the different types of discrimination faced by people. Also, if you look at the reasons for discrimination, race and ethnicity have been the two biggest reasons stated by the survey respondents that talked about the incidents that they faced. The next slide shows the breakdown of the reported ethnic backgrounds of the people that reported these incidents. A majority of them were Chinese Americans, but you can see many other ethnicities were all people from many other ethnicities were also targets or recipients of these discriminatory incidents. Not pictured here on the slide is also a statistic that 60% of people that responded were women and also specific types of discriminatory incidents were much more commonly seen in non-binary respondents compared to cis men and women of Asian origin. So at this point, it's really important to talk about the concept of intersectionality. Intersectionality is when you may have different, you may belong to different, more than one kind of minority population. And if you belong to a certain kind of minority population, you may have different experiences compared to other people who are in your community. For example, if you're a Asian American woman or Asian American person from the LGBTQ plus community, their experiences might be a lot different, unfortunately, somewhat worse compared to, let's say, a brown man. So at this point, I would like to invite my colleague, Dr. Poddar, again, to talk about microaggressions and the origins and the stereotypes. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Good job. Hello, everybody. This is Dr. Poddar. Thank you, Dr. Shah, Dr. Parekh, for such a wonderful introduction and the literature review. We're gonna talk about the microaggressions specifically in the South Asian Americans and propose the origins in their ethnic stereotypes. We also, per Dr. Oven, Dr. Parekh just introduced the concept of microaggression that it was introduced by Dr. Pierce, but Dr. Su actually was able to also classify them further and involve the other minoritized communities and divided them into the three types of microaggression, like the microassault, which is a little bit more on a conscious side of microaggression, microinsults, and microinvalidations that are more on the unconscious levels. The microassaults are something that are called the old-fashioned racism that are conducted more on the individual basis, whereas the microinsult is something where you negate the credibility of a person. The microinvalidation is where you invalidate a person's interethnic differences, just homogenizing the whole thing together. Now, because the microinsult and the microinvalidation are so subtle, Dr. Su actually also put in a term which is called as a psychological bind, which is where a person who is either the perpetrator or the recipient of these microaggressive terms are completely unaware that something like this even occurred to them. So now we can, important to know here is that microaggression basically depends on the perception of the person who is the recipient of it. So looking at the next slide, I want to take a little bit of time for you to orient what this slide is. So Dr. Su actually created this table where we have the microaggression in the top and then divide it into the tree, which is microinsult, microassault, and the microinvalidation, with the microassault more in the center because it's more on a conscious level. And the microinsult then has a different type of it, which is like the ascription of intelligence, which IE, I would say something like the model minority. And the microinvalidation is the alien in your own land as if you are a perpetual foreigner over here. Now when I talk about this, I often wonder about an example, like what good example would it be that sticks to our mind? So often when I hear about microinsult, an example that comes to my mind is a South Asian bestseller award winner. And at the award ceremony, receiving a comment that your people must be really proud of you. Really? For being a bestseller award? And the other would be that comes for the microinvalidation is when a South Asian American fashion designer is asked to host a whole show for him. He receives a comment from a manager saying that, are you sure you'll be able to manage this? Your designs are so exotic. Hmm, take a moment to think about that. Someone commenting about that to you. While there's a microassault, which is more on a conscious level, and the example that comes to my mind, and I often relate to this example, is when a South Asian American physician walks into the room and there's a Caucasian patient, they don't even make an eye contact. You greet them, they don't greet you back. But the first question that they ask you is, where are you from? Where did you do your residency? I don't want to see a South Asian doctor, please leave. I don't know how many of you relate to this. Please raise your hands if you have experienced any of that. Wow, thank you for your courage to even acknowledge that. Thank you, that means a lot. Here I'm gonna talk about now, it's so powerful when you feel those kind of feelings. I often wonder, where is it coming from? Like, you know, where is the microaggression towards the South Asian physicians, or South Asian Americans in general? Often I feel that it probably stems from the stereotype. It's like a stereotype that the South Asians are based on their ethnicity, their race, the name. We saw the name-based exercise, like it's difficult to pronounce those names. The history of immigration. And it often leads them to be the recipient of these microaggressions. They are also stereotyped based on their culture and their religion, to a point that, you know, an individual's personal belief is completely micro-invalidated in those situations. Oftentimes, South Asian Americans are linked, like, you know, as if they have those ties with terrorism, which really increased after the 9-11 attack. And we just saw Dr. Shah mentioning about, like, you know, the attacks on the Sikh that happened. And it doesn't happen just on the micro level, it has also gone on the macro levels. And most South Asian Americans are assumed to be like the new immigrants, as considered as a fresh off the boat, or maybe fresh off the Boeing, like as if you just stepped down from that flight, no matter which generation South American are you, South Asian American are you. And this invalidates them from being an American, and thus being a perpetual foreigner. The South Asian Americans are also tokenized as being obedient. While this could be true irrespective of the gender, but it's more commonly observed in women, where the intersectionality often leads to micro-insult. We just heard Dr. Shah mentioning about intersectionality that could occur. And I feel that there is a theme of tokenization, and where the South Asian Americans are micro-invalidated for their achievement, considering as if it comes from the quota. I would like to take a pause over here, and move your attention to another exercise before I talk about the other three that I have on the slide over here. And, you know, I want to take a moment of you, again, sharing a personal experience of mine. I know English is your second language, and the errors are minor. We'll work on them. I'll tell you where that statement came from. I had written an article, and I shared it with my senior just for a review, for their feedback, and this was the feedback I received. How many of you feel that this could be, A, micro-insult, B, micro-invalidation, C, micro-assault, D, all of the above, E, none of the above? Those who feel this is a micro-insult, kindly raise your hands. Thank you. Those who feel this could be micro-invalidation, kindly raise your hands. Thank you. Those who feel this is micro-assault, kindly raise your hands. Okay. Those who feel this could be all of the above. Oh, lovely. Thank you. And those who feel this is none of the above. Thank you. That'll be interesting to know your perspective. Did you have any comments on that? Really appreciate that comment. That is really one of the ways that we could all consider that. Thank you. But when it comes from someone who is from a South Asian background, where there's an underlying theme that English is not your first language, it really comes up first as if this is not where you're trained, and that is why you're written in this way. And in this slide, I would like to really stress about the microaggressive comments that come from people. Like, your English is really good. Where are you really from? I have a cousin just like you. You'd look prettier if you smiled more. And anybody resonates with any of these comments? Thank you. I think microaggression towards the South Asian Americans is often something like very unconscious based on the theme that, as I just mentioned, that English is probably not their first language. I apologize about this. The next concept that I really wanna talk about is the spokesperson phenomenon. And the spokesperson phenomenon, it is a theme where it negates the individuality and the actual experience of a person, and the person is expected to be a spokesperson for the entire nation or the culture that they may not even belong to. Often there's a statement that anybody who looks like a South Asian is often commented, are you an Indian? Do you eat Indian food? We just saw there are eight South Asian countries. They could be belonging from anywhere of those eight countries. But those are the kind of microinvalidation or microaggressive comments they are often exposed to. Often a time, this is also noted in children when they are in schools, where they are asked to describe about a cultural event that they may not be even celebrating. But they are expected to know everything and anything about it. This puts a lot of stress on a cumulative level, and my colleague, Dr. Gupta, will talk a little bit more about how these cumulative effects have on physical and mental health. And a lot of times, it also implies that probably you are a perpetual foreigner, and you don't belong here. It also could lead to a form of a racial trauma, and it could also reflect an imbalance and a misuse of power and authority. My next slide talks about the model minority myth. Dr. Shah just mentioned about that, that it was mentioned in first 1966 by New York Times, mentioning how the Japanese Americans were successful with their industriousness when they were facing all the racial discriminations that was going against them. But this term later on just spread across all Asian Americans, making it more like they are model minority, they are exceptional. And magazines like Times and Forbes have these Asian kids or Indian kids on forefront mentioning about the new model minority. Imagine the pressure it puts upon those kids, because you are portrayed to be someone who is exceptional based on the culture that you are coming from, and you are supposed to be successful. And in short, you are going to have a lot of academic achievement. I just want to stress about here that numerous studies have revealed that the concept is so inaccurate and harmful. Asian Americans are not smarter all the time, and other groups have more varying needs and abilities. And they're not always more emotionally stable that they are stereotyped and perceived to be. And this could lead to a lot of mental and physical stress that again, my colleague Dr. Gupta is going to talk about. I want to now lead your attention to another slide of mine where I feel that although the South Asian Americans are stereotyped or based on those terms that we just saw, I also feel that there's the stereotype that leads to their strength and their resilience. And South Asian Americans are stereotyped to have a culture, to encourage a family as a unit. And this provides them the strength and resilience to come together and address the concern of microaggression, developing their identity, developing their self-esteem. Something that Dr. Parikh just mentioned, self-confidence is so important to be developed. And I feel that sometimes we have that answer in our family as our culture, as our stereotype. The identity development in South Asian Americans are so complex because it involves a process of acculturation, the dominant culture, the communication styles, the linguistic backgrounds, the spiritual and all the other social networks that have been passed down by their elders down and deep rooted in their spirituality and tradition and the immigration history, which are so traumatic and, but at the same time, so hopeful that they give the skill and the strategies to persist and space despite being racialized by others. This gives me an opportunity to briefly mention about the strategies in a family as a unit and as an individual and in a community level, where it gives you an opportunity to not just be aware, but also identify and recognize that a microaggression has occurred and helps you to come together in your family and community to build up that racial self-esteem that you are able to now address these components of microaggression. However, we also just saw that how it could cause a lot of different effects on a cumulative basis and toxicity and I would now invite my colleague, Dr. Gupta to talk a little bit more about that. Thank you. Good morning everyone. Thank you, Dr. Vidar, for outlining the forms of microaggressions most prevalent within the South Asian populations. We'll now shift to looking at health and mental health consequences of microaggressions. So experiencing microaggression can signal the presence of a dangerous environment that results in physiological and psychological stress responses. And this idea that Dr. Parekh spoke about, and it was reiterated by my colleague Dr. Poddar as well, this accumulative burden of lifetime of microaggressions that are experienced by minoritized populations, it creates a state of perpetual stress that can contribute to both physical and mental illness and really flattens self-confidence. And that's a particularly challenging bit to treat clinically. Here we'll take a look at a figure that comes from a highly cited meta-analysis from 134 articles by Pasco and colleagues that looks at the relationship between perceived discrimination and both mental and physical health outcomes. Let me orient, start off by orienting you to the various oval boxes and the various pathways that do exist. So we'll start off looking first at, there's an obvious oval box that identifies perceived discrimination and the ultimate output is mental and physical health consequences. So there's a direct path A, directly from an insult, that is you experience some form of perceived discrimination that can result in mental and physical health consequences. Especially in individuals who've had a life history of experiencing a cumulative burden of microaggressions or individuals who have preexisting conditions and then there is this added set of microaggressions or an insalient event that really, you know, it's so potent that it goes directly from perceived discrimination all the way over to mental and physical health consequences. Moving to pathways B and C. So in this pathway, the relationship between perceived discrimination and mental and physical health consequences is proposed to be modulated, mediated by a heightened stress response. So perceived discrimination results in a heightened stress response. And this is the kind of stress response that can be chronic and perpetual in nature. And it is what actually leads to increased HPA axis stimulation, increased cortisol levels and over time, it progresses down to result in mental and physical health consequences. Additionally, looking down path D, in addition to heightened stress response is another factor that mediates mental and physical health consequences are health behaviors that are maladaptive, that are detrimental to one's health. So there's an insult perceived discrimination and then triggers you to engage in behaviors that are really not healthful, that are detrimental to your own health. And that then results in mental and physical health consequences. And let me go back to perceived discrimination, the box here right on the left. And from the way that Dr. Chester Pierce defined microaggressions, he defined it from the standpoint of the recipient, the target, and accumulative burden of that microaggression, it can really be seen as it encourages one to look at it as perceived discrimination. And from that mindset, when you go from the left to the right on this diagram, you're really recognizing that perceived discrimination is literally a social determinant of health and mental health. And it's important to keep note of this as we continue to progress forward in my discussion. And more importantly, let's also look briefly, which is to come back to this. At the bottom left, there is an oval box that identifies some protective factors that can be intervened, that can be implemented at the very earlier stages at points B and D, well before one reaches the level of heightened stress response or health behaviors. And these protective functions really help mitigate that elevated, chronic, perpetual stress response and keep an individual from engaging in behaviors that are not helpful, that are detrimental to their health. Moving forward, so having looked at the mechanism by which perceived discrimination can result in physical and mental health consequences, let's really take a closer look at some of the actual health consequences. Let's start off talking about health and cardiovascular consequences. And before I get started here, the amount of literature, research that is coming out suggesting how perceived discrimination and microaggressions can have an effect on one's mental health and physical health is abundant. There's no way that I could cover the amount of literature that is out there in one slide. It could be a talk or two just discussing that. But let's look at some of the factors that have been most readily identified. First we know that perceived racial and ethnic discrimination is linked to poor health and coping behaviors such as smoking, excessive alcohol consumption, and illicit drug use, which in itself increases cardiovascular disease. But there's also consistent evidence across studies that suggests a link between perceived discrimination, microaggressions, and elevated blood pressure and hypertension. Moving on to lower resting heart rate variability. Heart rate variability simply refers to the time frame between each subsequent heartbeat, the R to R interval. And there has to be some variability, and that variability is good. It's cardioprotective. But in individuals who have had repeated exposure to microaggressions, that cumulative burden of microaggressions or discrimination, they tend to demonstrate lower resting heart rate variability, predisposing them to higher levels of cardiac incidence. Moreover, moving down to the next point, elevated cortisol levels. Studies have identified that individuals who experience microaggressions, even at times just one microaggression and not just a repeated set of microaggressions, actually have elevated cortisol levels the very same day, and that persists till the next day as well. And given my own interest in biological mechanisms of microaggressions, I also wanted to look at, well, are there studies that suggest what exposure to microaggressions repeatedly time after time, what does it do at a biological level? And Kershaw and colleagues identified that it results in higher interleukin-6 levels, which is an inflammatory marker, which then results in elevated C-reactive protein levels and fibrinogen production in the liver. And what does that do? It accelerates plaque formation. It accelerates atherosclerosis, predisposing one to adverse cardiovascular incidence. And why are we talking about this? And why is this relevant when we talk about microaggressions in South Asians? And the reason for that is that the mediators of atherosclerosis in South Asians living in America, the Masala study that's been going throughout, across various institutions, look specifically at why South Asians tend to experience higher than normal when compared to their white counterparts' cardiac incidence and having control for genetic factors. So it's notable that South Asians are at a 2.1 times higher risk in general for cardiovascular incidence than white populations. And South Asians actually account for 60% of heart disease cases, although they only make up a quarter of the planet's population. And for these reasons, understanding the cumulative burden of microaggressions in South Asians and subsequent physical and mental health consequences is paramount. It's really, really essential why we look at cardiovascular consequences that come about because of microaggressions and how they affect South Asians. And microaggressions can result in a wide array of mental health output. Some of these listed here are symptoms, but there have also been various studies that have been correlated with various diagnoses. Experiencing microaggressions can result in severe psychological distress, anger, anxiety, depression, PTSD, OCD, paranoia, substance use, alcohol misuse, reduced self-esteem and self-efficacy, relating back to the fact that repeated exposure to microaggressions, the cumulative burden, can really defeat and flatten out one's sense of self-confidence, suicidal ideation, homicidal ideation, and chronic stress as well. So we just talked about symptoms and diagnoses. But another thing that doesn't get talked about as much is that microaggressions contribute to barriers to treatment. It really undermines trust. So looking at Pathway D, what tends to happen is that repeated exposure to microaggressions undermines trust among individuals of colors and minoritized populations, leading them to seek out medical care less often, if and at times not at all, or only when it is absolutely necessary, when there's no other option available. So we'll look at a series of studies at this point, just to further illustrate the various pathways that we just spoke about and how they come through. So in this particular study that was published in the American Journal of Public Health, Sorer and colleagues demonstrated that merely anticipating prejudice can lead to both psychological and cardiovascular stress responses. So what they did was they identified Latina females who were advised that they would be involved in providing feedback to Caucasian women. They were told that these Caucasian women, that they would be providing feedback to harbor ethnic and racial biases and oftentimes hold eguitarian values. And over the process, they monitored their cardiovascular responses, they monitored their heart rate, their blood pressure, their EKGs, and noted throughout the study, in addition to the cardiovascular markers, they also noted subjective reports of prejudice and also just the fact that there were higher levels of stress that was experienced even before engaging in such behaviors. And it highlights that allostatic load, you know, the idea that you experience cumulative burden of chronic stress in life events, that results in a number of health consequences. It can result in depression as well as it can anxiety as well as it exacerbates cardiovascular responses and decreases immunological functioning. Next study here was published in the Journal of National Black Nurses Association where Johnson and colleagues identified that in a group of 350 African American women between the ages of 18 and 71, they noted that there were higher rates of emotional eating behaviors in women who reported higher perceived discrimination and higher stress levels. Again, looking at pathway D, perceived discrimination can result in maladaptive detrimental health behaviors, which can then further, through cyclical nature, proceed to path E to result in further mental and physical health consequences downstream. And now we're going to look at a series of studies that have looked at microaggressions within South Asian Americans. Punita Rice examined retrospective reports in about 10 college-age South Asian Americans and had them describing their experiences with racial microaggressions related to being asked to speak about Indian or South Asian culture or for their cultures, essentially serve as spokespersons for their cultures. And they noted that in such experiences, such experiences really harm student self-esteem and increase susceptibility to depression and anxiety, as well as places individuals at heightened risk for racial trauma and anxiety. In 2019, a study by Srinivasan at Columbia University looked into experiences of name-based microaggressions relating to the study, the exercise that my colleague Dr. Poddar started off with among South Asian populations and identified that racial microaggressions through name mispronunciation can lead to internalized racism for students of color. And at this point, you know, I really wanted to share a personal anecdote as well. I was nine years old in the fourth grade attending school at the American Embassy School in Bangkok in Thailand. In my art class, we had students, it's an international school. Students come from all over the world. And my art teacher approached me, my name is Dhruv, and she commented, well, why is it that parents give their children such difficult-to-pronounce names? And I was nine. And then the follow-up comment was, would it be okay if I call you door or dog? And I was nine. I wasn't sure how I was processing that. I was a bit insulted and, you know, I just felt, well, what am I supposed to say? My immediate response at the time was, well, a dog's an animal. Well, it'd be fine if I call you a pig. And obviously, it wasn't well taken. I was called to the principal's office. My parents were also called to the principal's office as a nine-year-old. As a nine-year-old, I was terrified. The oldest kid, you know, there's pressures that come along, you know, do well at school, you know, be respectful, be loving, and whatnot. But what I was taken aback was by the principal's approach to this situation. She really highlighted that we cherish diversity. We have people coming in from all over the world, and this is not the behavior that we model. And, you know, my parents were right there with the same stance, and it ended up being sorted out. But it highlights that a lot of us in this room have really experienced, you know, variations of other names. And they're just not variations of other names. They feel, they are microaggressions. They are. And they have an effect on you. They make you question, who am I? Like, what's going on? Why am I so different? So I just wanted to share that personal anecdote with you, as it found it highly relevant, you know, as I was reviewing this particular study. I do not go by door. I do not go by dog. Just clarifying that out there. Moving forward, another study that I really like. Manijwala and Aburas looked at experiences of religious-based discrimination on campus among 12 Muslim South Asian female undergrad students across universities in the United States, and really asked them about their experiences with microaggressions. And even those, and even individuals who weren't readily identified as Muslim, they reported that all of them had experienced microaggressions. And the perpetrators were both their colleagues and also professors. But highlighting the need for strategies that should extend across training levels and disciplines, and not just targeted at, you know, the student body. Strategies should be looked at both the individual, the interpersonal level, community, systemic organizational level. And many of the recipients of such painful remarks, you know, after processing it themselves, they took it upon themselves to change these painful experiences into moments of education. They took it upon themselves to educate their colleagues, administration, leadership. And that brings us to the point of minority tax, which, you know, we talk about a lot as part of our diversity leadership fellowship. And I'm not sure if Dr. James is here, but, you know, she gave us a lecture on it not too long ago. And she talked about it, really, you know, it comes down to the individual that is being subjected to such comments, such remarks, has to not only deal with the own toll of working and processing through that, but then also take on that added effort to creating an environment where they clearly identify this is not, this is something that can be hurtful. And again, highlights the importance for having allies and strategies at the community, institutional, and organizational level to truly step in and make a difference. And then one last study that I wanted to bring up is Nadenh Pali and colleagues analyzed data from 866 participants in the Masala study, the mediators of atherosclerosis in South Asians living in America. And they looked at the association between self-reported discrimination and dietary intake among South Asians. And they noted that South Asians consume higher amounts of South Asian and American sweets when faced with discriminatory practices. They tend to manage the distress that comes about with discrimination, discriminatory practices, by consuming sugar, by consuming foods that are rich in carbohydrates and fats. And interestingly and not surprisingly, experiences of discrimination were not related to higher levels of fruit and vegetable consumption. They were related more with consuming donuts and gulab jamuns and tiramisu. And also there's a list of desserts on there. So pointing that out. And really looking at the impact of microaggressions during the pandemic currently in the sense from the perspective of healthcare workers, we're really recovering from two epidemics. These past two years have been really incredibly tough. And we have seen the intersection of a pandemic that has caused significant psychological distress for healthcare workers, higher likelihood for exposure, fatigue, lower emotional support, and also racial microaggressions and macroaggressions. We had the Black Lives Matter attacks and hate against varied minorities. I know my colleague Dr. Shah spoke about some most recently, the hate crime a little over a week ago in Buffalo, New York, and their impact create additional emotional vulnerability for healthcare workers. Not only as being members of those community, but also having to work with such discrepancies and discriminatory practices and hate that exists within the community and the emotional impact of microaggressions can be equal to, if not greater than overt discrimination as it was pointed out by Dr. Pierce, because the cumulative burden can flatten self-confidence and oftentimes you're left wondering, well, what was just said? Was it directed at me? Was it not directed at me? At least with overt microaggression or overt acts of discrimination, it's very clear that was directed at me, but you're not left thinking as you are in microaggressions, well, what could have happened or what could be happening there? I'd like to close off talking about some of the changes that have come about and which I'm incredibly pleased about. It was graciously pointed out by Dr. Francis Liu in a recent conversation that I was having with him. He pointed out that for the first time under the cultural and social structural issues of the brand new DSM-5 text revision, the term microaggressions is included and defined. It also appears in the index on page 1,031 in case if anybody wants to go back and look. Its implications on physical and mental health are considered and it has literally taken 50 years since when Dr. Chester Pierce in 1970s coined the term and to its inclusion in DSM-5 TR. In addition to that, there is a Z code that has been included, target of perceived adverse discrimination or persecution Z60.5. And again, these changes go on to highlight that and also discussion on the various health and mental health consequences that microaggressions when looked through the definition of Dr. Chester Pierce as something that is subjectively experienced, something that is understood from the standpoint of the individual receiving it can be looked at as perceived discrimination and that is literally a social determinant of mental and physical health. And at this point, I would really like to thank Dr. Francis Liu and the entire DSM-5 text revision committee for their efforts to consider the cumulative burdens that stressors have on one's health and mental health consequences. And I'll bring back the audience to this diagram right here. You know, we have looked at the different pathways, but let's talk about some of the protective factors that do exist. Having social support, adequate group identification, coping styles. These are really protective functions. Even after you have experienced some form of discrimination, if these measures are in place, they can and they target up at points B and point D much before the effect of a heightened stress response or leading an individual to detrimental health behaviors, maladaptive health behaviors, and that, more than any of the other pathways, this is most interesting to me, I would imagine, just because there's stuff that we can do as clinicians, as mental health care clinicians, psychiatrists, psychologists, to really step in and really intervene at a point where the impacts become, where impacts really take toll on the patient's health. And I'm excited that we have a lot of time this afternoon to really engage audience, to look at some of the individual strategies, to look at organizational and institutional strategies, to see what can we do and also discuss and engage everybody in discussion surrounding their own experiences. But right before we get to that, I would like to call on stage our co-chair, Dr. Ramaswamy Viswanathan, to speak briefly about some of his work and organizational strategies that APA in itself has implemented. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. My early career colleagues really given exemplary talks on covering various aspects of microaggression. I would like to highlight a couple of issues. We all know that immigrant stress adds to the risk of developing psychiatric disorders. But we need to, stress is a very vague term. We have to get into the specific aspects of stress that we can modify. And one of them really pertains to our sense of belonging and how we are perceived by the rest of the society. And this is an elegant study done in Denmark by Drs. Wehling, Susser, and others, not sorry, in Netherlands, in The Hague, where there are pockets with high concentrations of immigrants, basically people from Morocco, Suriname, and Turkey. And these neighborhoods were labeled by them as high ethnic density neighborhoods, whereas the rest, which are predominantly white, were considered low ethnic density neighborhoods. And if these minorities, if they were living in a low ethnic density neighborhoods, then the risk of developing psychotic disorders was 2.36 times higher. So what is it, you know, it's not simply we are talking about immigrant stress, it's also talking about which kind of neighborhood you are living in. In fact, they did a final analysis of that, and they found that the risk for Moroccans was higher for the Surinamese, it was intermediate, and for the Turks, it was lower. And you can see for Moroccans, it was 4.43, the relative risk ratio, whereas for Turks, it's 1.74. So why is that so? So one hypothesis is discrimination. They also, based on population studies, they had index of discrimination, it so happens in the Hague, people from Morocco, they face the highest discrimination, and people from Turkey, among these minority ethnic groups, actually, the lowest discrimination is for people from Western countries. And so this seems, there seems to be an association between discrimination and risk of developing mental illness. And it's interesting that even though you may be facing discrimination, if you are living among people like you, then you are not at that much significant risk. So one possibility is, if you are living among people among yourselves, you are not facing micro-aggression, especially micro-invalidation. You have a sense of identity, who you are is valued, whereas if you are a minority in a predominantly white situation, and it's possible you are constantly, your identity is challenged, your custom is challenged, you undergo micro-invalidation, and that seems to be a tremendous stress. Another example is, often people talk about stereotype against Asians, in which you have a positive and negative element. This incident happened in our school district, wherein a white girl started a Facebook group, headaches non-Asians must stick together. So it's targeted towards a particular ethnic group. And she asked, is anyone else sick of our school winning every academic award because of the Asians? And so even, it's a positive prejudice, but at the same time, she didn't like it. And then the negative element is directed towards the food, or having to hold their noses while walking through the cafeteria. Our school district is actually very harmonious. People, parents, as well as administrators, we all work together, and we all promote diversity and inclusion. And fortunately, in this incident, the parents and the administrators didn't have to get involved at all. Nobody rose up in arms. The students really had a harmonious discussion in face groups, as well as in small groups themselves, and they really sorted out. There were issues on both sides, and by open discussion, everybody became harmonious, and the group continued. And one of the students did an investigative report on this. This further spread the different opinions to the entire readership, and the local newspaper picked up on it and published it. This way, even the community became aware of it. So when we respond to microaggression, we want it to be at a constructive level, and this was one example of that. And how do we address microaggressions? We really owe a lot, all of us, in minorities in United States, we are facing a lot of benefits, which we wouldn't have faced about 30 years ago. And a lot of this, the fact that we are treated much more fairly than might have been in the past, and our inclusion, we owe it a lot to the civil rights movement and the women's movement. Even at an individual level, if you are facing any oppression or microaggression, you can always look to the examples of black leaders, as well as women leaders, and you can learn a lot in what strategies to do at an individual level. Just to give a brief history within our own organization, the APA, obviously there has been a lot of emphasis placed on recognizing racial disparities within the organization, and addressing that, and promoting inclusion, and APA has done a lot and continues to do a lot. The origins, again, belong to these two movements, and especially, initially, the black psychiatrists were formed in 1969, and then the Association of Gay and Lesbian Psychiatrists was formed in 1978, and in 1983, the Association of Women Psychiatrists was formed, so these are all members movements. Initially, the caucuses and special interest groups were formed by the members, but then also, it leads to the APA forming Council on Minority and National Affairs, which was inclusive of all minority and underrepresented groups, both ethnic minorities, as well as LGBT and women, and also, in 2013, the board created a seat for representation of minority and underrepresented groups. At the administrative level, APA formed what was called Office of Minority and National Affairs, and now, it was renamed recently as Division of Diversity and Health Equity, and our own Dr. Rana Parekh directed that division till a couple of years ago, and this division has been wonderful in promoting diversity and inclusion and giving a lot of opportunities, and which many of our trainees have taken advantage of, including Drew. And so, what can individuals and family and the community do? Much of microaggression happens in schools. Children, they are immature and also vulnerable, and I think the parents have to really be active. You have to talk to your children and find out what's happening at school, and then you have to really equip the children to how to deal with them, and in some instances, obviously, you have to speak to school administration, and many immigrant families do not understand the importance of parent-teacher association. It's very important for the parents to participate, both to figure out if there are any microaggressions or overt aggressions. If it is discussed in the parents' group, these parents, again, are going to spread the word to their children, and that can be a more harmonious resolution of these problems, and also to help learn from each other, and it's very important for PTAs to organize various community events celebrating various cultures. This happens in our Herrick School District, and in fact, we even have a forum called the Community Coalition, which was formed decades ago by Jewish immigrants when they were minorities, and we all are beneficiary of now because everybody comes together, various minority groups, and also the majority groups, and we have a productive discussion. And also, at an individual level, also, we need to train our patients whom we are treating through assertiveness training, and because there are appropriate ways of solving the problems, and also not so appropriate ways. Most of all, it's very important. We all practice microaggressions, and often without our awareness. We have to sensitize ourselves to be aware of it, and we should be the change that we want to see in others, as Mahatma Gandhi stated so wisely. And now I turn it over to our moderator, Dr. Parekh. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. I'm excited for the audience to engage in some discussions at the individual level strategies, interpersonal, I'm gonna call those PIG strategies from now on, or community family strategies or organizational strategies. Some good news, APA stopped recording at 75 minutes, so let's get into some good trouble here and talk about ways that we can come up with proactive strategies. Dr. Frank-Clark, I'm gonna call on you first because you are a leader on so many levels at APA, and the AMA, so what are some strategies for organizations, professional medical societies? All right, good morning, or I guess good afternoon. And I never can turn down a question from one of my mentors, Dr. Parekh, so hopefully I'll answer this well. But one of the things that I'll start with where I met at Prisma Health in South Carolina where I've been practicing now for about five years, we're very intentional about talking about microaggressions, so not only at the medical school level, but in residency and at the C-suite level. So for example, I'm on a diversity, equity, and inclusion task force at the University of South Carolina School of Medicine, Greenville, and we're looking at ways that we can increase awareness as it relates to the DEI framework. I've given talks to medical students. Actually, they get a talk, the first year is right before they start. There's like a little orientation, so to speak, and they have found that talk on microaggressions to be helpful. Same thing with residents. I think, too, from an organizational level, people have to have a safe space, and so oftentimes that doesn't happen, and so I think we have to be thinking about psychological safety when we're talking about people who are recipients of microaggressions to be willing to know who can they talk to. Allyship is one thing. We talk about the bystanders and what do you do with that. I've personally been, oh, and by the way, this was a wonderful talk. I really enjoyed this. I've been the recipient of multiple microaggressions as a black male, and so it's always good to hear from individuals from various demographics, whether it be race, ethnicity, sexual identity to talk about. We're all in this together, and I think we have to really be intentional about putting pressure on the organizations, whether it be where I'm at, or AMA is doing a lot of work as well, so we created, I was on the task force that was responsible for creating the Center for Health Equity, and Dr. Aletha Maybank is the chair of that, and she has been putting her foot on the gas, and she has not taken it off of making sure that our House of Delicates, our leaders, are really looking at how this impacts all of us. That illustration with the perceived stress and all the deleterious effects that we know about, I think showing that to the C-suite individuals is very important because we're talking about life expectancy and longevity, and we know about telomeres and weather rain and how that impacts us all, so those are just some of my comments. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Hi, I'm gonna use this mic so we don't have to all turn our heads. Thanks, Frank. Thank you for this. As my Tabla teacher used to say growing up, shabash. I probably butchered that, but as the token, no, spokesperson, ABCD in the room. Who understands that? No, I was confused growing up. So I'm gonna ask, I'm gonna say one comment disguised as, or one question disguised as a comment and one question straight up, which hopefully will cause some good trouble. Okay, so. Okay. First of all, this is the closest thing we're gonna get to a South Asian caucus, so I feel really happy about that. We were hoping leadership was gonna be in the room, but I hope that's not recorded. I hope that gets to the nest, Frank. Hopefully you can take it there. We need a space, actually, and I'm very heartened by this. It's incredible. It's literally incredible what you've done, and I'm blown away, actually. Training was really tough for me. Actually, I learned early on, if I just shut my mouth, people would think I was probably good at biology, and I think about that, and I realized the privilege of my accent, so very quickly I would start talking so people know that I'm from New York or what have you, and I was at a wedding in the midst of my residency when it was really, really, really hard, and the white man, he was a tall, handsome white man, and he says to me, man, you've got some bravado. Where did you grow up, and this and that? And I said, oh, I grew up in New Jersey, and he said, who are your friends? I said, oh, I had a bunch of white guys who were my friends, and he said, oh, that's how it happened, and I'm thinking in my head, motherfucker, no. The reason I can stand tall is because my father taught me how to stand tall, even though I'm not tall, and I wear platform shoes, but it's also because of all of you all. I stand on the shoulders of my brothers and sisters who have worked so much harder. Every single time it was hard for me, it took me seven years to get through four years of medical school, I'm dyslexic, didn't tell anybody that, and I just think to myself about my cousins, about the Kaplan Center, where I met all my foreign brothers and sisters, and I'm like, we work so freaking hard, so that's a big windup to my question, which is, all right, so there was a multiple choice, and you said, is this an insult to aggression? I guess my question is, that person who gave you that comment, how could they have said it, and convey what they were trying to convey? Thank you for that question. That's really a very pertinent question, because I was an international medical graduate, so when I came in, so it was a kind of a comment which felt as if they are giving a constructive feedback, but it did feel very insulting and micro-invalidating, all my efforts that I had taken, and someone from the audience had said that it could be an imposter syndrome, but I often wonder, this was something that came from the person who was reviewing my work, so it felt more as micro-aggression, and less as imposter, because it came from someone else, but it just felt as if whatever I do is not gonna be enough. So the way he said it, what about word choice, because I think- That was exactly the word choice. No, I'm saying what could he have said, or she said, like how would you phrase it? Because it was so assumed that English is my second language, had they just said that, we feel that there are some grammatical errors, or something which was more constructive way, rather than assuming that I'm coming from a second language, English, yeah. Gotcha, gotcha, gotcha, gotcha. Because the last point I was gonna make about that is what I've learned, speaking to that bravado, or whatever it is, when you work, I'm a child adolescent psychiatrist in New York City, and what I've learned is with, especially like 16 to 24 year olds, you have to match affect, so I don't know, I'm just posing. One of the things that is like, it's like the obedience that you talked about, that like they assume that you're gonna be, you're gonna just take whatever thing is, I wonder, I pose this question to all of us, like maybe we can, I don't know, just, I don't know, fight it back a little bit, and I don't know how to do that, it's gotten me in trouble, but I ask. I completely agree. In fact, Amartya Sen, who is one of like the well-published writer, has said that Indian-Americans, not that in general all the other South Asians, we are not as compliant, we are not as complacent like it would be. We are able to talk back, but it's tough. We have to learn those strategies, and I appreciate that. Thank you. Thank you everyone, great presentation. It really kind of highlighted a lot of blind spots that I had, you know, just everything, every slide was like, oh yeah, that happened to me, so thank you for that. You know, one of my questions is, maybe sounding a little narcissistic, but as you move up a little bit in leadership positions, and I, you know, definitely for Dr. Parekh, and how, you know, it becomes, you know, the air gets thinner, right? As you move up in leadership position, you're managing, say, a big group, or it becomes even more difficult. For me, double thing is, as an immigrant and as a minority, how do you kind of manage those things as you move up in leadership position, and those things that start, you know, all the dynamics that start playing in that position? Yeah, it's a great question. It does get lonelier at the top, and you know, I will look at some other folks here who are also very senior and have done great work. I think you have to stay grounded. You know, a big part of the PASCO study and the diagram that Dr. Gupta showed, you know, having social supports and being grounded is really, really important. You know, I pull something out of my head all the time that Dr. Pierce always taught me. He was the ultimate and the consummate mentor. He taught me how to navigate dominant cultures. I mean, he and I were both at Mass General. He was probably the first and only African American and person of color for many, many, many years. And even though Asians are not considered minorities at Harvard, it was kind of always interesting to me that there weren't a lot of people who looked like me or of the similar background. But I think always sort of thinking about the end goal, what you're trying to accomplish, having a very strong social support, being very grounded in that, and always knowing that you have a BATNA. You know, I do a lot of work around collaborative negotiations and how does one always have a plan B, C, D, and E and to not act like a prisoner. So, if it ever got really, really bad, knowing you could leave, but otherwise working through and navigating dominant cultures by paying a lot of attention, talking less and watching more, and then building allies. You know, Deepak Panasetty is also, you know, leading our minority fellowship programs at the APA and we're so lucky to have him, because I think the fellowship program builds a national network of people that increases your social supports. Dr. Pierce talked a lot about having mentors outside of your organization, having supporters outside of your association so that you can have that strong network and always have a plan B, but also strategize, because each of these strategies are very unique. I mean, I probably couldn't pull off the pig comment that Drew did, because that's just not who I am, though it's a great strategy. So, you've got to find things that are also very, you know, in sync with who you are. But, great question. Can I call upon Dr. Liu? I know a lot of people are waiting. I apologize. Dr. Liu, yeah, we would like to hear from you. Yeah, Francis Liu, I thank you very much for your wonderful presentation and also mentioning about the changes in the text revision that was just published March 19th. And just to reiterate, in the introduction to the DSM now, there is a specific section that's entitled Impact of Racism and Discrimination on Psychiatric Diagnosis, where you highlighted microaggressions being actually stated and defined. That's the first time that's happened in the DSM. And also, consistent with the theme of this meeting, something we all know, it is stated in black and white, it's in the TR, racism is an important social determinant of health. And it goes on to cite the many conditions that you discussed here today. And then I also wanted to end by saying that it says that other adverse consequences of discrimination include unequal access to care, that you brought up, and clinician bias in diagnosis and treatment, which leads to that. And finally, clinicians should make active efforts to recognize and address all forms of racism, bias, and stereotyping in clinical assessment, diagnosis, and treatment. So that means not only getting this as part of the history that patients have experienced, and perhaps fulfilling the Z code category as a distressing experience involving perceived discrimination, but also looking at our relationship with our patient in terms of this bias issue, and how we are actively causing problems, and how we need to correct them as well. So again, thank you very much. Thank you, Dr. Liu. Thank you. Thank you. Yeah. So Dr. Sandra, and then we'll go back, and then, yeah. Thank you very much to all of you, and to all of the speakers. Particularly thank you, Rana, for calling on Frank Clark, because I think this is so important that we build this cross-ethnic, cross-identity solidarity. So I'm going to flip, first flip that slide of the sweets that Drew put up, and call this a collab-jamoon, collaborative jamoon. I love it. I love it. Yeah, I think this is a very good thing. So I just wanted to maybe categorize something. So we are up against it, and how we take what we're up against determines our outcomes. I think what are we up against? A dominant culture. And I have an acronym now that I just generated here, it's UTSU. So is it, how does a dominant culture categorize us? Are they categorizing us as a utility? Are we disposable? Are we scapegoated as a threat? Or does it just plain not understand us? Okay, so I think all of these things could be going on, and so our awareness is sharp. Only the person who is in the moment knows what they think is going on. But culturally, all these things are going on. But we are up against it. And I would say that the overall sense of what we're up against is a very hierarchical dominant culture against a more relational point of view, which we emphasize in our profession as psychiatrists. So this is a challenge that's coming down to us on individual levels, but it's a collective problem of this hierarchy versus relational. And so it's a demand that we be understood, and that we understand ourselves as we face it. So thank you very much. Thank you. Thank you. Thank you for that acronym. Thank you. I'm Raghu Appasani, another ABCD, from the Northeast as well. Had some white friends too. Yeah, it's definitely been a struggle. The one area I wanted to ask more about was microaggressions within our own community. And growing up, there was a lot from my parents about telling us about their own struggle, but kind of just this environment of keeping your head down and proving your worth through becoming educated and not fighting back, because there is such a fear to fight back or to say something that you'll be at a disadvantage. And so I think my question is, how do we... We're talking a lot about changing the conversation when we're speaking to other ethnicities or communities, but how do we also change that within our own culture? And I also do a lot of work in India through my NGO, and even there, going as an ABCD, there's other whole issues with that situation too. So it's almost like, as someone who was born here, that question of where you're really from still happens. People don't believe me when I say I'm from Boston or whatever, and then if I'm in India, they obviously know I'm not born in India. So we're kind of... It's not even third culture, right? It's like another level of where are we from? So I've been really conflicted now where I'm trying to speak up more in certain settings, but always having that voice in my head from growing up. It's a balance of fear of losing opportunities or getting pushback if we do speak up. So yeah, I'll leave it at that. And I'm currently missing my poster session too. But this is incredible, and thank you for doing this. So your question is great. I don't want you to leave quite yet. I know you're late. But we have the president of the IAPA next, and I know she's been championing this issue, but we do need to start with our own home. I was part of a presentation that we gave at ANSEPS. For those of you who may know ANSEPS, it's the Indian Diaspora meeting that takes place in India every winter. This year was virtual. And the excitement and electricity around this topic was palpable. It's so interesting. CAST, of course, came up in so many different ways, and we've unfortunately brought that to this country. And wherever we go, there's a massive study, a lawsuit right now with Cisco Corporation. Some of you may have heard two friends who studied at IITT in India. One is Dalit, and the other one Brahmin. And they ended up working together at Cisco in California, and the Brahmin would make fun of the Dalit and talk about how he got to IITT because of affirmative action. The one who's Dalit complained to HR. They didn't understand what that meant, and despite this, he was continued to be harassed. And now it's like a $100 million lawsuit. So people like me who are chief diversity officers, we learn CAST system because it is a real thing. So I think we have a lot to learn, and I do believe we need to start with our own home and we can lean in on our colleagues, particularly I think the Black Caucus has done a lot of work in this area. Not only do they have effective strategies that we can lean in on, but things that have not worked. So we need to work, you know, as Dr. Chandra said so beautifully, we need to work together with lots of groups, and we need to think about our own microaggressions and the things that we're responsible for. But President Baghi is next. I want to let her talk. I'm sure she has some great ideas. Well, I just wanted to congratulate you all. You did an amazing job, and I'm also thankful to the APA for allowing this kind of presentation and to, you know, have – pay attention to this. This has been there for a long time, and it brings back memories of my residency days because we had a very – we had an attending that was extremely difficult with the Asian residents. It brings back memories and even, you know, emotions. And my own personal experience – this was almost 40 years ago, and he gave me a three out of ten for the ECT rotation. He was an ECT attending, and that was completely out of character for the – compared to the rest of my, you know, evaluations. And fortunately, I stood up against that, and I went to the chairman and Dr. Alan Taylor, who was a pioneer at that time, and he was completely with me. So unless you – somebody is there to stand up for you, he said, this evaluation is negated, and it was taken off my average, and he actually even had a conversation with the attending. So I think that the strength to stand up comes from your own self-confidence. And 40 years later, I'm sure it still, you know, exists, but then all these conversations and these, you know, forums, I think, brings attention to all the microaggressions and the macroaggressions. So I commend you on that, and I congratulate all our IAPA members, and thank you for acknowledging the Indo-American Psychiatric Association, and again, thank you all for bringing this up. Great job. Yes, thank you so much for this topic, because it's, like, under-discussed, and I really feel the need to share. I know that we're already over time. We need to stand up. I had a wake-up call yesterday. Dr. Parekh, I was in your talk on supporting underrepresented trainees. The very next talk I went to was a young person who was giving a wonderful talk on intersectionality, and she asked for feedback from the audience. Now, she did have an accent throughout her presentation, and she was very passionate, and there was one of us, right? This was right here at the APA. A Caucasian man, middle-aged, raised his hand and said, well, you have an accent. He said that. My jaw dropped. None of us were prepared to, like, respond to that, and so it actually just got glossed over and went on to the next thing, right? Fortunately, one of the senior attending on the panel later said, oh, I didn't want to gloss over something that just happened. She was trying to be pretty nice about it and saying, you know, sometimes people say things and it just doesn't get received the way that you intended. You may come with good intentions, and that comment about her accent, like, was that really necessary? Right away. Well, you know, I evaluated people for boards, and they didn't pass because of their accents. As my trainee later pointed out, they said, he probably didn't pass the people accents, right? Patients need to be able to understand you totally just, you know, you know, I hope so, so that somebody could review this, because worse than that, then we're breaking up into small groups, right? So they said, you know, reach out to the neighbors around you. So there's an older lady of color sitting next to me, and I talked to her, and she's like, oh, no, no, no. She's like, I'm not a doctor. I'm just here to watch, right? And so I was like, oh, I wonder if that's, like, a family member, right? So I said, do you have a family member up there? And she's like, oh, yeah, that's my daughter. Oh, my gosh. I am completely embarrassed by our profession, by the APA. That was an and, okay, as the woman was trying to discuss this with the man, he was getting kind of, he's loud, you know, like nobody, it was, we were conflicted, because at the same time, this great group had prepared this talk on a different topic, right? And so she said, well, should we keep discussing this? I'm not sure, you know, then there was silence, then another Caucasian man raised his hand and said, let's just move on. So we moved on, right? So I would have liked to know what can we, we need to, you know, I want to share this with you. Please share it with your other friends. I've been presenting here every year since 2015. Thank you, Dr. Parekh, for all your support for our College Mental Health Caucus. I've been attending, I've never seen that happen before. So we have to be prepared to respond and be an upstander. So there's a need to speak up, and I would love to hear, Dr. Parekh and any of you, right, you know that, you know that people who attend, what is the way to respond to, it was very inadequate and unsatisfactory. Dr. Parekh, I'll just let you speak. Thank you so much for bringing that up, and I'm surprised that this incident happened. But again, this is, this goes to show that microaggressions happen all the time, and you know, sometimes we're on receiving end, but sometimes we're on the giving end unknowingly. So I think one of the individual strategies is, so like in your example, not staying silent and speaking up is really important, but oftentimes what happens is that the defense, the giver of the microaggression may say, well, I did not mean it, but just to say I didn't mean it, you know, you may have felt that way, but I didn't mean it. So I think when that's something that you politely bring up and address to the person giving out the microaggression, I think it's important to say, well, thank you for clarifying that your intent was not that, and thank you for allowing me to clarify the impact this has had, because your intent may not have been that, but I would love to educate you on how this has impacted me personally or how it might impact somebody. So even if your intent may not have been that way, you need to recognize the impact. Yeah. I wish somebody had defined microaggression. Oh, yeah. I just want to add that at a residency training level, process groups are quite important. You know, I had a process group when I was a trainee, and then now in my program, I make sure all the residents are in process groups. So that's an occasion wherein microaggressions are discussed, and people also have to become aware that they are engaging in microaggression, so it educates, you know, everybody, and that's one way, at least at the residency training level, we can promote more inclusivity. So we're going to talk about, I want to give you a solution, actually. Thank you. So, Dhruv is going to mention something, and then I'm going to follow that up. Sure. So I'm not sure if, first of all, I'm horrified to hear about this incident from you. I answered that, too, at an annual APA meeting on the social determinants of health and mental health. Like, how does this happen? Like, I'm mind boggled. But one of the projects that the fellows worked on, the Presidential Task Force on Structural Racism, was creating an anonymous feedback portal within APA, and somehow it is there, and one of the struggles that we're working with is that piece of information hasn't disseminated to folks as well as we've wanted to, despite our efforts to reach out to various forms of leadership, and regrettably, Saniya Bharani, who was here in the audience just a bit ago, she had to leave. But the two of us had worked together to create this portal. It is anonymous. You can report anonymous incidents that take place within the APA, and this is, you know, it doesn't get any more within the APA than the annual meeting. So I would highly encourage, I mean, to bring this incident up, put it in there, and talk about it. I mean, there was just so much material today that we could have spoken about in terms of strategies, but one of the things really is, when you see something, you step in, you lay the ground rules, identify what the principles of the institution are, and make appropriate adjustments and provide the education that is required to amend that behavior, correct that behavior, because this is not what APA stands for, and this is not what's tolerated. So I really hope you look at the, and I'm happy to, you know, share the link with you. It's on the website? Is that right? Yeah. So it is, it's, there's an article in Psych News as well. It launches reporting system for incidents of structural racism. So if you go on the APA Presidential Task Force for Structural Racism and Social Determinants of Mental Health, and you scroll down, there's a list of resources that the fellows have created in terms of reading recommendations, and directly below it is a link for anonymous feedback portal. So that is a link where I would encourage, you know, for this to be brought up, and as a fellow, I would be motivated to do this with my other co-fellows. Thank you for bringing this up. Thank you. Thank you for bringing that up, and maybe a couple of us could do this for you in addition to you, because I think the numbers will help you. Thank you for sharing that, and sorry that happened. Really sorry. Dr. Opako? Yeah. Samuel Opako. I want to thank you all for your excellent presentations. All the speakers have been very excellent. For just one minute, I want to share with you the need to be aware of people in positions at the APA. When I came to this country, I was doing a Ph.D. here, and my supervisor was a president of the APA, and at the meeting of the Society for Culture and Psychiatry in New Mexico, they said that stereotypes are true, and if you are aware, you notice that a few months ago, a former president also made some negative comments about black beauty, so the fact that somebody is an official of the APA does mean that they are sufficiently aware and sensitive. At the same time, though, we need to make sure we don't victimize ourselves. You know, we need to come with strength, we need to be aware, and we need to protect ourselves. Thank you. Thank you. Thank you so much. Thank you. Thank you so much. Thank you so much for those comments. We just have two quick slides of acknowledgment. I also just want to affirm everybody in the audience for staying beyond the time period and for— It speaks volumes. Yes, it speaks volumes, and we're so appreciative for those of you who could share vulnerable comments and stories and those of you who are continuing to create good trouble everywhere, so just a couple of quick slides. So, you know, just wanted to highlight that we're all in this together. This was a statement that came in in an email that was forwarded to us by Dr. Liu, and just reading it really quickly, we know that we cannot address anti-Asian racism without addressing anti-black racism and xenophobia, nor can we move towards racial justice without moving forward together. We'll never stop working towards a future where we can all live freely and without fear. So we're all in this together. We can't end just South Asian microaggressions by just focusing on South Asians. We need to take a stance on social justice that spreads beyond just what affects us directly. So that's the message we wanted to leave all of you with, and the passion that we bring to clinical care, patient care, and research, that's exactly the same passion that we need to bring to diversity, equity, inclusion, and addressing matters that you just brought up as well that happened yesterday. That same passion has to come into our day-to-day work. This talk is dedicated to our very dear Dr. Chester Pierce, and we have some acknowledgements, of course, Dr. Rana Parekh, Dr. Viswanathan. I think my colleagues, Dr. Poddar and Dr. Shah, would agree wholeheartedly that we would not be standing here giving this presentation without their relentless support over weeks and months and the rehearsals we have had for it as well. Sorry, I'm looking at the thank you slide, but additionally, I wanted to thank Dr. Frances Liu as well, and Dr. Connie Dunlap, the IAPA, and all of you for coming in, for staying so late and really making this an engaging discussion. Our references are all here. I know we are running low on time, but feel free to stay back if you want to take pictures of them. Thank you. Thank you so much. I really appreciate it.

Microaggressions

South Asian Americans

Mental Health

Community Strategies

Dr. Ronna Parekh

Dr. Manan Shah

Dr. Karuna Poddar

Dr. Dhruv Gupta

COVID-19 Pandemic

Anti-Asian Hate

Model Minority Stereotype

Perpetual Foreigner Label

Stress Response

Hypertension

Cardiovascular Disease