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LeGrand S, Reif S, Stringfield B, Cooper H, McDonald J, Wilson S. Project uplift: a behavioral health intervention for transgender and non-binary young adults. HPHR. 2021;43. DOI: 10.54111/0001/QQ1
Transgender and gender non-binary (TNB) individuals are disproportionately impacted by mental health disorders, substance use, and suicidal ideation and attempts than the general population.1–4 In addition, TNB individuals are more likely to experience stress due to trauma, stigma, discrimination, victimization, under/unemployment, housing instability, and lack of access to gender affirming behavioral healthcare, all of which contribute to poor behavioral health outcomes.1,5–8 In the southern region of the US, where the largest number and proportion of TNB individuals reside, cultural conditions that contribute to significant LGBTQ+ stigma and discrimination, racism, fewer educational and employment opportunities, and greater overall poverty further compound the risks of behavioral health disparities.9–12
Table 1. Project Uplift staff roles and relevant demographic characteristics
Staff role in Project Uplift | LGBTQ+ | POC | LGBTQ+ & POC | |||
| n/N | % | n/N | % | n/N | % |
Case manager | 1/3 | 33.3 | 1/3 | 33.3 | 0/3 | 0% |
Individual and/or group counselors | 10/14 | 71.4 | 10/14 | 71.4 | 6/14 | 42.8 |
Project Uplift was developed to fill a critical need for behavioral health services for LGBTQ+ young adults, aged 18-35, in Charlotte and Durham, NC and surrounding areas. While open to all LGBTQ+ identified individuals, we are particularly focused on providing services to TNB individuals of color. Project Uplift, influenced by the Gender Minority Stress and Resilience model,13,14 provides 6-months of free evidence-based, gender-affirming services including intensive case management, support groups, and individual and group counseling. Currently, nearly all services are provided virtually.
Intensive case management, provided by case managers knowledgeable and experienced in providing affirming services to TNB clients, is an essential program component as the services help clients to address major stressors including those related to housing, employment, and legal document changes; if unaddressed these often contribute to poor behavioral health outcomes.8,15,16 Reducing these and other relevant stressors (e.g., anticipated stigma, inadequately trained providers) also increases the likelihood that clients will engage in and benefit from behavioral health services.17,18 Our unique model of contracting with highly diverse counselors from the community, many of whom are LGBTQ+ and/or people of color (POC) (Table 1), to provide counseling offers clients an opportunity to identify counselors they feel most comfortable working with. Given that many of the clients report negative experiences with past therapists who lacked proficiency in providing gender-affirming services, it is of utmost importance that clients feel safe and receive high quality, affirming counseling services through Project Uplift.
The ability to offer multiple treatment modalities for individual therapy such as Cognitive Behavioral Therapy (CBT), Dialectical Behavior Therapy (DBT), Cognitive Processing Therapy (CPT), and Acceptance and Commitment Therapy (ACT) based on client needs further strengthens the likelihood that counseling services will improve behavioral health outcomes. Clients collaborate with program counselors to determine their stage of readiness and interest in the different types of treatment modalities and formats (i.e., individual, group counseling). Therapeutic groups have used different evidence-based treatment modalities to match varying degrees of clients’ readiness for participation. For example, ACT groups have appealed to some clients reluctant to engage in other modalities such as DBT. In addition, groups for clients and counselors who share identities, such as BIPOC autonomous groups, have been offered. These groups provide a therapeutic space to address additional stressors experienced by those who occupy multiple minoritized intersectional identities. Support groups offer general peer support and education creating a space to engage with other TNB individuals and reduce social isolation.
Study participants have primarily been recruited through local agencies that serve LGBTQ+ individuals, word of mouth, and social media advertisements. Program eligibility criteria include: 1) age 18-35; 2) identify as LGBTQ+; and 3) reside in the Durham or Charlotte geographic areas. Participants complete surveys measuring demographics, behavioral health stress and resilience factors (e.g., housing, employment, gender identity-related stigma & resilience) and behavioral health outcomes (e.g., depression, anxiety, sexual health) at baseline and post-intervention (6-months) to examine changes over time.
Table 2. Baseline demographic characteristics of Project Uplift participants
Demographic characteristic | N | % |
Gender identity |
|
|
Nonbinary | 32 | 41.5 |
Transwoman/woman | 23 | 29.9 |
Transman/man | 18 | 23.4 |
Other | 4 | 5.2 |
Race |
|
|
Asian/Asian American | 3 | 3.9 |
Black/African American | 25 | 32.5 |
Multiracial | 6 | 7.8 |
White | 38 | 49.3 |
Refused/don’t know | 5 | 6.5 |
Ethnicity |
|
|
Hispanic or Latino/x | 12 | 15.6 |
Non-Hispanic or Latino/x | 64 | 83.1 |
Don’t know | 1 | 1.3 |
Sexual identity |
|
|
Bisexual/pansexual | 27 | 35.1 |
Queer | 22 | 28.5 |
Gay/lesbian | 12 | 15.6 |
Straight | 9 | 11.7 |
Other | 4 | 5.2 |
Asexual | 3 | 3.9 |
|
|
|
| M | SD |
Age (in years) | 27.8 | 5.7 |
Table 3. Baseline behavioral health stress and resilience factors
Behavioral health stress or resilience factor | N | % |
Housing (where living most of the time) |
|
|
Shelter | 2 | 2.6 |
Street/outdoors | 1 | 1.3 |
Own/rent apartment, room, or house | 47 | 61.0 |
Someone else’s apartment, room, or house | 27 | 35.1 |
Current employment |
|
|
Full-time (35+ hours/week) | 29 | 37.7 |
Part-time | 24 | 31.1 |
Unemployed | 21 | 27.3 |
Don’t know | 3 | 3.9 |
Has a doctor or provider for gender affirming medical care |
|
|
Yes | 39 | 50.6 |
No | 8 | 10.4 |
Missing | 30 | 39.0 |
How much doctor or provider for gender affirming medical care knows about providing care to the LGBTQ+ community (n=39) |
|
|
Almost everything | 15 | 38.5 |
Most things | 10 | 25.6 |
Some things | 7 | 17.9 |
Almost nothing | 2 | 5.1 |
Not sure | 5 | 12.8 |
I feel part of community of people who share gender identity |
|
|
Strongly disagree/disagree | 33 | 42.9 |
Strongly agree/agree | 41 | 53.2 |
Missing | 3 | 3.9 |
I feel connected to other people who share my gender identity |
|
|
Strongly disagree/disagree | 34 | 44.2 |
Strongly agree/agree | 40 | 51.9 |
Missing | 3 | 3.9 |
I would like to be more connected to other people who share my gender identity |
|
|
Strongly disagree/disagree | 9 | 11.7 |
Strongly agree/agree | 65 | 84.4 |
Missing | 3 | 3.9 |
I am comfortable revealing my gender identity to others |
|
|
Strongly disagree/disagree | 28 | 36.4 |
Neither disagree nor agree | 11 | 14.3 |
Strongly agree/agree | 35 | 45.4 |
Missing | 3 | 3.9 |
The way I live shows other people that stigma against gender diverse people is wrong |
|
|
Strongly disagree/disagree | 3 | 3.9 |
Neither disagree nor agree | 26 | 33.8 |
Strongly agree/agree | 44 | 57.1 |
Missing | 4 | 5.2 |
Because of my gender identity, I feel like an outcast |
|
|
Strongly disagree/disagree | 19 | 24.7 |
Neither disagree nor agree | 19 | 24.7 |
Strongly agree/agree | 36 | 46.7 |
Missing | 3 | 3.9 |
I have experienced difficulty getting identity documents that match my gender identity |
|
|
Yes | 48 | 62.3 |
No | 17 | 22.1 |
Don’t know/refused/missing | 12 | 15.6 |
I have had difficulty finding or keeping employment due to my gender identity |
|
|
Yes | 27 | 35.1 |
No | 40 | 51.9 |
Don’t know/refused/missing | 10 | 13.0 |
I have been rejected or distanced from my family because of my gender identity |
|
|
Yes | 46 | 59.7 |
No | 25 | 32.5 |
Don’t know/refused/missing | 6 | 7.8 |
I have been verbally harassed or teased because of my gender identity |
|
|
Yes | 52 | 67.5 |
No | 19 | 24.7 |
Don’t know/missing | 6 | 7.8 |
Housing (where living most of the time) |
|
|
Shelter | 2 | 2.6 |
Street/outdoors | 1 | 1.3 |
Own/rent apartment, room, or house | 47 | 61.0 |
Someone else’s apartment, room, or house | 27 | 35.1 |
Current employment |
|
|
Full-time (35+ hours/week) | 29 | 37.7 |
Part-time | 24 | 31.1 |
Unemployed | 21 | 27.3 |
Don’t know | 3 | 3.9 |
I feel part of community of people who share gender identity |
|
|
Strongly disagree/disagree | 33 | 42.9 |
Strongly agree/agree | 41 | 53.2 |
Missing | 3 | 3.9 |
I feel connected to other people who share my gender identity |
|
|
Strongly disagree/disagree | 34 | 44.2 |
Strongly agree/agree | 40 | 51.9 |
Missing | 3 | 3.9 |
I would like to be more connected to other people who share my gender identity |
|
|
Strongly disagree/disagree | 9 | 11.7 |
Strongly agree/agree | 65 | 84.4 |
Missing | 3 | 3.9 |
I am comfortable revealing my gender identity to others |
|
|
Strongly disagree/disagree | 28 | 36.4 |
Neither disagree nor agree | 11 | 14.3 |
Strongly agree/agree | 35 | 45.4 |
Missing | 3 | 3.9 |
The way I live shows other people that stigma against gender diverse people is wrong |
|
|
Strongly disagree/disagree | 3 | 3.9 |
Neither disagree nor agree | 26 | 33.8 |
Strongly agree/agree | 44 | 57.1 |
Missing | 4 | 5.2 |
Because of my gender identity, I feel like an outcast |
|
|
Strongly disagree/disagree | 19 | 24.7 |
Neither disagree nor agree | 19 | 24.7 |
Strongly agree/agree | 36 | 46.7 |
Missing | 3 | 3.9 |
I have experienced difficulty getting identity documents that match my gender identity |
|
|
Yes | 48 | 62.3 |
No | 17 | 22.1 |
Don’t know/refused/missing | 12 | 15.6 |
I have had difficulty finding or keeping employment due to my gender identity |
|
|
Yes | 27 | 35.1 |
No | 40 | 51.9 |
Don’t know/refused/missing | 10 | 13.0 |
I have been rejected or distanced from my family because of my gender identity |
|
|
Yes | 46 | 59.7 |
No | 25 | 32.5 |
Don’t know/refused/missing | 6 | 7.8 |
I have been verbally harassed or teased because of my gender identity |
|
|
Yes | 52 | 67.5 |
No | 19 | 24.7 |
Don’t know/missing | 6 | 7.8 |
Table 4. Baseline behavioral health outcomes
Behavioral health outcome | N/M | %/SD |
Serious depression in past 30 days | N | % |
Yes | 60 | 77.9 |
No | 16 | 20.8 |
Missing | 1 | 1.3 |
|
|
|
| M | SD |
Days of serious depression in past 30 days (n=60) | 18.6 | 10.0 |
|
|
|
Serious anxiety in past 30 days | N | % |
Yes | 67 | 87.0 |
No | 9 | 11.7 |
Missing | 1 | 1.3 |
|
|
|
| M | SD |
Days of serious anxiety in past 30 days (n=67) | 21.6 | 9.1 |
|
|
|
Alcohol or illegal drug use in past 90 days | N | % |
Yes | 48 | 62.3 |
No | 28 | 36.4 |
Don’t know | 1 | 1.3 |
|
|
|
Alcohol use in past 30 days (n=49) | N | % |
Yes | 40 | 81.6 |
No | 9 | 18.4 |
|
|
|
| M | SD |
Days of alcohol use in past 30 days (n=36) | 8.4 | 8.7 |
|
|
|
Illegal drug use in past 30 days (n=49) | N | % |
Yes | 28 | 57.1 |
No | 16 | 32.6 |
Refused/Don’t Know | 5 | 10.2 |
|
|
|
| M | SD |
Days of illegal drug use in past 30 days (n=25) | 16.5 | 10.6 |
|
|
|
Marijuana use in past 30 days (n=28) | N | % |
Yes | 28 | 100 |
No | 0 | 0 |
|
|
|
| M | SD |
Days of marijuana use in past 30 days (n=28) | 16.2 | 10.6 |
|
|
|
Sexual activity (oral, anal, vaginal sex) in past 30 days | N | % |
Yes | 42 | 54.5 |
No | 27 | 35.1 |
Refused/missing | 8 | 10.4 |
|
|
|
| M | SD |
Number of unprotected sex encounters in past 30 days (n=41) | 8.4 | 16.3 |
|
|
|
Have you ever been tested for HIV? | N | % |
Yes | 47 | 61.0 |
No | 25 | 32.5 |
Don’t know | 5 | 6.5 |
Table 5. Type and number of Project Uplift services provided
Type of service | N |
Case management services | 903 |
Individual counseling sessions | 386 |
Group counseling (# participants) | 41 |
Support groups (# participants) | 48 |
Since October 2020, 105 LGBTQ+ individuals have enrolled in Project Uplift, 77 of TNB experience: nonbinary=32; transwoman/woman=23; transman/man=28; other=4. Of these, nearly 1/3 identified as Black/African American and 15.6% Hispanic or Latino/x; the average age was 27.8 years (Table 2). Participants endorsed both behavioral health stress and resilience factors (Table 3). The majority of participants had experienced depression (78%) and anxiety (87%) in the last 30 days, and 62% identified substance use in the past 90 days (Table 4). Engagement and retention strategies have been successful; TNB clients engaged in 1289 case management services or individual counseling sessions, 89 participated in a therapeutic or support group since program initiation (Table 5) and 87% of clients were retained at 6-months.
Examination of clients’ behavioral health indicators and stress and resilience factors in combination with high services utilization and retention data indicate a critical need for gender-affirming behavioral health and intensive case management services for TNB young adults in North Carolina. Future analyses will examine changes in behavioral health stress and resilience factors and behavioral health outcomes during the 6-month intervention. If there are promising improvements, we will pursue additional funding to further and more rigorously test the model.
Project Uplift is supported by the Substance Abuse and Mental Health Services Administration (SAMHSA) through award number H79-TI081999 (S. LeGrand/S. Reif, Project Directors). The authors would like to thank the participants of Project Uplift for taking part in the study.
The authors have no relevant financial disclosures or conflicts of interest.
Dr. Sara LeGrand (she/they) is an Associate Research Professor at the Center for Health Policy and Inequalities Research and Duke Global Health Institute at Duke University and Co-director of the Duke Sexual and Gender Minority Health Program. Her research focuses on understanding and addressing health disparities among sexual and gender diverse populations around the world.
Dr. Susan Reif (she/her/hers) is a Research Scholar at the Center for Health Policy and Inequalities Research at Duke University with a doctoral degree in Health Policy and Administration. She is the principal investigator for three federally funded projects addressing behavioral health among individuals living with HIV and the LGBTQ+ community.
Beth Stringfield (she/her/hers) is a research project leader with the Center for Health Policy and Inequalities Research with over 20 years of experience in project development and leadership.
Haley Cooper (she/her/hers) is a project coordinator with the Center for Health Policy and Inequalities Research with experience in providing case management, project development and implementation and data analysis.
Jess McDonald (they/them/theirs) is case manager with the Center for Health Policy and Inequalities Research with extensive experience in providing services in the LGBTQ+ population.
Dr. Sarah M. Wilson (she/her/hers) is an Assistant Professor in the Department of Psychiatry & Behavioral Sciences at the Duke University School of Medicine and a practicing, licensed clinical psychologist at the Durham VA Health Care System. Her clinical work and research focus on provision, development and implementation of interventions to promote health equity among populations that experience systemic oppression, including low-income individuals, sexual and gender minorities, and people of color.
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