John Paul Sánchez

Health Care Utilization, Barriers to Care, and Hormone Usage Among Male-to-Female Transgender Persons in New York City

OBJECTIVES We investigated health care utilization, barriers to care, and hormone use among male-to-female transgender persons residing in New York City to determine whether current care is in accord with the World Professional Association for Transgender Health and the goals of Healthy People 2010. METHODS We conducted interviews with 101 male-to-female transgender persons from 3 community health centers in 2007. RESULTS Most participants reported having health insurance (77%; n = 78) and seeing a general practitioner in the past year (81%; n = 82). Over 25% of participants perceived the cost of medical care, access to specialists, and a paucity of transgender-friendly and transgender-knowledgeable providers as barriers to care. Being under a physicians care was associated with high-risk behavior reduction, including smoking cessation (P = .004) and obtaining needles from a licensed physician (P = .002). Male-to-female transgender persons under a physicians care were more likely to obtain hormone therapies from a licensed physician (P < .001). CONCLUSIONS Utilization of health care providers by male-to-female transgender persons is associated with their reduction of some high-risk behaviors, but it does not result in adherence to standard of care recommendations for transgender individuals.

Racial and ethnic minority medical students' perceptions of and interest in careers in academic medicine.

Purpose To describe diverse medical students’ perceptions of and interest in careers in academic medicine. Method In 2010, the authors invited students attending three national medical student conferences to respond to a survey and participate in six focus groups. The authors identified trends in data through bivariate analyses of the quantitative dataset and using a grounded theory approach in their analysis of focus group transcripts. Results The 601 survey respondents represented 103 U.S. medical schools. The majority (72%) were in their first or second year; 34% were black and 17% were Hispanic. Many respondents (64%) expressed interest in careers in academic medicine; teaching and research were viewed as positive influences on that interest. However, black and Hispanic respondents felt they would have a harder time succeeding in academia. The 73 focus group participants (25% black, 29% Hispanic) described individual- and institutional-level challenges to academic medicine careers and offered recommendations. They desired deliberate and coordinated exposure to academic career paths, research training, clarification of the promotion process, mentorship, protected time for faculty to provide teaching and research training, and an enhanced infrastructure to support diversity and inclusion. Conclusions Medical students expressed an early interest in academic medicine but lacked clarity about the career path. Black and Hispanic students’ perceptions of having greater difficulty succeeding in academia may be an obstacle to engaging them in the prospective pool of academicians. Strategic and dedicated institutional resources are needed to encourage racial and ethnic minority medical students to explore careers in academic medicine.

Medical and Support Service Utilization in a Medical Program Targeting Marginalized HIV-infected Individuals

Background. One strategy to facilitate HIV health care services utilization is to incorporate support services with medical services. We developed a program that delivers HIV medical care and support services to marginalized people, and evaluated the association between support and medical services utilization. Methods. We extracted data on 218 newly enrolled program participants 3 months prior to through 6 months after program enrollment, and analyzed associations between support and medical services. Results. Case management visits (AOR=1.95, 95% CI 1.04–3.67) and group visits (AOR=2.59, 95% CI 1.30–5.16) were associated with greater odds of quarterly medical visits. Outreach visits were associated with greater odds of having a medical visit in a traditional medical setting (AOR=2.31, 95% CI 1.15–4.67). Conclusion. Case management, support groups, and outreach were associated with HIV medical visits. Further research exploring how integration of support services into HIV medical programs can improve health care delivery is crucial for health policy and program development.

Cigarette smoking and lesbian and bisexual women in the Bronx.

This study investigated the prevalence of cigarette smoking, smoking patterns, and smoking cessation efforts of Black and Hispanic lesbian and bisexual women from a poor, urban community. One-on-one interviews were conducted with a convenience sample of 130 self-identified Black and Hispanic lesbian and bisexual women from the Bronx, NY. Bivariate statistics were used to determine differences between Black and Hispanic respondents in smoking prevalence, frequency, desire to quit, and impact on family unit. Fifty-five percent of Black respondents and sixty-two percent of Hispanic respondents were current smokers. Hispanics were more likely than Blacks to have a partner (p < 0.04), 2 or more children (p < 0.05), and an asthmatic in their household (p < 0.02). Hispanics were less likely than Blacks to have ever attempted to quit (p < 0.04) and to have made a serious attempt to quit in the past year (p < 0.02). Culturally sensitive interventions are needed to help Hispanic lesbian and bisexual women move from the pre-contemplative to action stage of quitting. The large proportion of current smokers requires greater access to effective smoking cessation tools.

Commentary: the building the next generation of academic physicians initiative: engaging medical students and residents.

Data from the 2010 U.S. Census are a reminder of the diverse patient population in the United States and the growing health care needs of Americans. Academic health centers are tasked with reforming the system to expand its capacity for care and with cultivating innovation to generate the teaching, training, and research prowess needed to eliminate health disparities. At the center of this reform is enhancing the system that produces the human capital, including the physicians who care for the patients and the educators who train those physicians. Institutions and foundations have committed to the development of pipeline programs, from kindergarten through college, to create a diverse clinical workforce, but they have limited their direct promotion of diversity in the academic medicine workforce to faculty development programs. Despite faculty efforts, shortcomings in diversity persist, including a paucity of female full professors and deans, an insignificant increase in the proportion of underrepresented racial and ethnic minority faculty, and a lack of knowledge on the cultivation of the lesbian and gay faculty perspective. Furthermore, underrepresented racial and ethnic minority students in particular lose interest in academic medicine careers during medical school, and overall students lose interest in academic medicine careers during residency. The Building the Next Generation of Academic Physicians Initiative is designed to develop interest and promote achievement in pursuing academic medicine careers. This initiative is needed to increase the pool of diverse faculty down the road and elicit their perspectives to more effectively address health care disparities.

Assessment of a Medical Outreach Program to Improve Access to HIV Care Among Marginalized Individuals

Marginalized populations are disproportionately affected by HIV, yet they have poor access to health services. Outreach programs focus on improving access, but few are evaluated. We assessed a medical outreach program targeting unstably housed, HIV-infected individuals. We extracted data from 2003-2005 to examine whether keeping medical appointments was associated with patient and program characteristics. Patients kept appointments more frequently when they were walk-in or same-day appointments (compared with future appointments; adjusted odds ratio [AOR]=1.69; 95% confidence interval [CI] = 1.38, 2.08), when they were at a community-based organizations drop-in center (compared with single-room occupancy hotels; AOR=2.50; 95% CI=1.54, 4.17), or when made by nonmedical providers (compared with medical providers; future appointments: AOR = 1.38; 95% CI = 1.05, 1.80; same-day appointments: AOR = 1.70; 95% CI = 1.03, 2.81). These findings demonstrate the importance of program-related characteristics in health services delivery to marginalized populations.

Eliminating LGBTIQQ Health Disparities: The Associated Roles of Electronic Health Records and Institutional Culture

For all humans, sexual orientation and gender identity are essential elements of identity, informing how we plan and live our lives. The historic invisibility of sexual minorities in medicine has meant that these important aspects of their identities as patients have been ignored, with the result that these patients have been denied respect, culturally competent services, and proper treatment. Likely due to historic rejection and mistreatment, there is evidence of reluctance on the part of LGBT patients to disclose their sexual orientation (SO) or gender identity (GI) to their health care providers. There is some perception of risk in sharing SO and GI for many patients who have had bad prior experiences. Despite these risks, we argue that we can improve the quality of care provided this population only by encouraging them to self-identify and then using that information to improve quality of care. One strategy both to prompt patient self-identification and to store and use SO and GI data to improve care centers on the use of electronic health records. However, gathering SO and GI data in the EHR requires a workforce that knows both how to obtain and how to use that information. To develop these competencies, educational programs for health professionals must prepare students and educators to elicit and to use sexual orientation and gender identity information to improve care while simultaneously ensuring the safety of patients, trainees, and staff and faculty members as SO and GI become openly discussed and integral parts of ongoing medical discussion and care. As determination of SO and GI demographics becomes more common in health research, we will more fully understand the health risks for all the LGBTIQQ populations.

Prioritizing health disparities in medical education to improve care.

Health and health care disparities exist for specific populations worldwide. These populations—defined by race/ethnicity, socioeconomic status, gender identity, and sexual orientation, among other attributes—are the human capital with whom institutions must partner to achieve educational, clinical, and research excellence in health disparities. Partnerships that foster shared leadership will enable academic health centers (AHCs) to be at the vanguard of providing quality, population-based health care and in addressing disparities. We propose the development of heightened partnerships between underserved communities, institutions of higher learning, AHCs, and federal agencies to tackle health disparities through institutional and community commitment and accountability, new governmental incentives and regulation, and an enhanced physician workforce.

Educational video tool to increase syphilis knowledge among black and Hispanic male patients.

Study objective. To determine the effectiveness of an educational video entitled Syphilis and Men to increase syphilis knowledge among at-risk Black and Hispanic male patients. Methods. In this randomized controlled trial, participants were randomly assigned to one of four groups and completed a pre-test survey, viewed the video (intervention group) and/or completed a post-test knowledge survey. Our analysis assessed whether the intervention group in comparison to the control group had an increase in syphilis knowledge, regardless of self-reported socio-demographic and sexual behavior characteristics associated with increased risk for syphilis infection. Results. Two hundred and six (206) males were studied. The intervention group participants scored on average 24.8 percentage points higher than the control group participants (p<.001) on the post-test survey after viewing the video. This difference was present regardless of certain self-reported socio-demographic and sexual behavior characteristics associated with increased risk for syphilis infection. Conclusion. The Syphilis and Men video is a five-minute, low-cost tool that increased syphilis knowledge among Black and Hispanic male patients and could have similar effects in other settings.

A Syphilis Control Intervention Targeting Black and Hispanic Men Who Have Sex with Men

There are no documented syphilis control efforts targeting Black and Hispanic men who have sex with men (MSM) despite recent syphilis outbreaks among MSM and the disparate burden of syphilis among minorities. Methods. A syphilis control intervention, named the DL STATS PARTY, was designed to promote syphilis testing among minority MSM, through a sexual health and general well-being framework. Results. Of the 461 MSM with complete intake data, the average age was 27.0, 44.7% were Black, 42.7% were Hispanic, 67.9% had sex with two or more partners in the previous six months, and 28.4% reported sex with a female in the previous six months. Although Blacks accessed fewer overall services and physically invasive services, race/ethnicity was not a factor in choosing to be tested for syphilis. Conclusion. The DL STATS PARTY promoted syphilis testing among at-risk Black and Hispanic MSM. The program conforms to the CDC Recommended Steps to Mobilizing the Community to Address Syphilis and has the potential to be an example for other U.S. metropolitan areas.