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 ( 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.

Public Health Relevance

The proposed project targets transgender women, a population facing a disproportionate burden of violence and mental disorders. The proposed research will adapt and test a novel, scaleable and potentially cost- efficient mHealth intervention (RISE) to improve violence reporting, identification of mental health needs and referral to care among transgender women. If successful, the intervention could be scaled up and adapted to other populations and countries

National Institute of Health (NIH)
National Institute of Mental Health (NIMH)
Exploratory/Developmental Grants (R21)
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Dissemination and Implementation Research in Health Study Section (DIRH)
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Horvath Marques, Andrea de Fatima
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Centre for Addiction and Mental Health
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