Project Summary The approximately 1.6 million Americans who are Transgender or Gender Diverse (TGD)—individuals with gender identities that differ from their sex assigned at birth—are impacted by an extraordinarily high incidence of negative mental and physical health outcomes compared to their cisgender peers. Such outcomes include mental distress, suicide, substance use issues, and HIV and other sexually transmitted infections. These health inequities are attributable to “upstream” or structural factors, including systematic societal, political, and economic marginalization, medical pathologization, and violence. Research points to rampant multilevel access barriers for TGD people and major social needs that undermine engagement in healthcare. There is a public health imperative to develop healthcare interventions to reduce disparities for TGD people by facilitating access to and engagement with appropriate services, addressing their unique Social Determinants of Health (SDoH), and integrating them into the social fabric of communities. Structural interventions target the social causes of ill- health, inadequate and fragmented treatment, and inequalities affecting TGD people. In partnership with TGD community members, we created a structurally competent adaptation of the evidence-based Critical Time Intervention (CTI), a robust case management program originally developed for persons with serious mental illness transitioning from institutions into communities, to ameliorate the disparities that impede the full integration of TGD people into healthcare systems. We will rigorously implement and evaluate this TGD-specific adaptation (CTI-T) in New Mexico service systems and analyze impacts on TGD people exiting institutional settings, including shelter care and residential programs, hospitals, and jails/prisons. We will cultivate meaningful collaboration and inclusion of diverse partners to enable structural competency and CTI-T uptake at the multiple levels where care barriers exist by applying Implementation Mapping, a participatory process for planning and selecting implementation strategies (methods to adopt and implement interventions). We will leverage a seminal implementation model, the Interactive Systems Framework, to guide efforts to embed CTI-T in professional service delivery contexts. A real-time evaluation of implementation and impact using a mixed-methods approach will facilitate dual testing of the CTI-T and its implementation strategies. By innovating CTI to prioritize structurally competent approaches, this study responds to the dearth of evidence-based intervention research targeting the SDoH responsible for the well-documented access barriers and excessive morbidity and mortality faced by TGD people.

Project Narrative Compared to their cisgender peers, Transgender or Gender Diverse (TGD) people—individuals with gender identities that differ from their sex assigned at birth—are impacted by an extraordinarily high prevalence of negative mental and physical health outcomes and have major unmet social needs due to structural factors, including systematic societal, political, and economic marginalization, medical pathologization, and violence. Using a structural competency framework that considers the external forces shaping health outcomes at levels above individual interaction, this study will implement and evaluate a TGD-specific adaptation of the Critical Time Intervention (CTI), an evidence-based case management program, for TGD people, and develop implementation strategies to facilitate its uptake in under-resourced health and human service systems. This theory-driven, mixed-methods research will produce data targeting the structural factors responsible for the well-documented access barriers and excessive morbidity and mortality faced by TGD people.