Transgender women (TGW) disproportionately experience physical/sexual violence when compared with the
general population and with other sexual and gender minorities (SGMs). A recent systematic review identified a
high prevalence of lifetime physical (68%) or sexual violence (49%) among TGW. Frequent experiences of
violence contributes to high levels of posttraumatic stress disorder (PTSD), generalized anxiety disorder
(GAD), suicidality, substance use disorder (SUD) and might influence the onset, progression, and prognosis of
major depressive disorder (MDD) among TGW. Since 2008 Brazil is responsible for more than 40% of all
transgender homicides reported worldwide. In 2016/17 we conducted a survey with 2,846 TGW from twelve
Brazilian cities, identifying 60% prevalence of lifetime violence (physical and/or sexual), 60% of participants
screened positive for MDD, 38% for GAD, and 35% attempted suicide. The majority of violent incidents were
not reported to the police (91%) and most victims did not receive any counseling or mental health (MH)
treatment (82%). On this resubmission, we will utilize community-based participatory research (CBPR) to adapt
the “UNI-FORM” app and online platform (https://uni-form.eu) to TGW from Brazil. The study specific aims are:
(1) Refine and adapt the “UNI-FORM” mHealth intervention to Brazil (RISE), including MH screening and link
to MH care; (2) Pilot test RISE to prevent violence, improve MH screening and treatment; and (3) Evaluate the
feasibility and acceptability of RISE. This R21 exploratory project proposes to recruit 200 TGW from Rio de
Janeiro, Brazil to study the implementation of RISE. Consistent with NIMH goal to enhance research capacity,
the proposal is led by an early stage investigator and includes a close collaboration with researchers from
Duke who will provide constant supervision from researchers with senior expertise in SGM mHealth (Dr.
Legrand), SGM MH international research (Dr. Whetten), MH and implementation science (Dr. Belden). This
proposal is innovative in several ways: it will adapt to Brazil an existing mHealth intervention addressing
SGM-related violence (UNI-FORM), to include additional features to increase MH screening and linkage to MH
care. The proposed app, RISE, has the potential to improve crises response and promote timely MH care
among a high-risk population: TGW. It has significance and impact: The intervention will prevent and respond
to violence against TGW, in a country with the highest rate of transgender murders in the world. It will also
develop an innovative strategy to identify and link to care TGW who need MH care, a population with high
prevalence of PTSD, GAD, MDD, SUD and suicidality. Those mental disorders are underscreened,
underdiagnosed, and undertreated among TGW. If successful, the intervention could be scaled up and
adapted to other populations and countries. This research will yield the crucial first steps in developing a lower
cost and efficacious mHealth intervention that we plan to evaluate with an RCT in a subsequent R01. RISE
addresses all three NIMH priorities identified in the Notice of Special Interest in Research on Health of SGM
Populations (NOT-MD-19-001), Grand Challenges in Global Mental Health and NIMH Strategic Aim 3.
