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.
