TransHealthGUIDE: Transforming Health for Gender-Diverse Youth Using Interventions to Drive Equity

修订后的摘要 变性人和性别多元化(TGD)青年(15-24岁)的性别认同与出生时指定的性别不同，是NIH指定的健康差距日益扩大的人群。TGD青年的自杀率高于他们的顺性同龄人；超过一半的人在有生之年考虑自杀。这些和其他健康差距对于TGD青年来说是雪上加霜的，他们是黑人或西班牙裔，经历了基于性别和种族的耻辱和少数族裔压力。黑人青少年的自杀风险也在增加；从1991年到2017年，自杀未遂增加了73%。迫切需要干预措施，以改善TGD青年，特别是TGD青年的心理健康，他们也是少数族裔。我们提出了一种变革性的、多层次的干预措施，通过个人、人际、 系统性和以社区为基础的变化，增加提供者、青年和照顾者的知识和支持，从而减少自杀和改善心理健康。已知提供者和家庭/照顾者支持是TGD青少年心理健康结果的关键决定因素，但没有大规模干预措施来解决这些可补救的结构和社会健康决定因素。我们的干预包括两个部分。第一个是供应商培训和支持计划。这需要一个免费的继续教育学分在线培训课程，教提供者如何支持TGD患者并与其有效沟通，以及一个提供者网络，以增加心理社会支持。第二个是面向TGD青少年和照顾者的互动教育数字平台。数字平台通过教育模块提供专家生成的知识，并使用互动功能来促进沟通和加强青年与照顾者之间的关系。我们将使用多阶段优化策略(MOST)框架来优化平台，以便在立即ARM(前期访问)和延迟ARM(6个月访问)的混合有效性实施试验中进行测试。每个ARM的干预期将持续6个月，然后是长达12个月的观察期，并继续进入。使用有效的子量表，我们将评估前三个月报告自杀意念的个人比例(主要结果)、心理痛苦和焦虑、照顾者支持和医疗授权(次要结果)的变化，以及剂量效应、跨组治疗效果的异质性和组内弹性因素的变化。这一创新的多层次干预满足了TGD青年面临的健康差距的短期和可持续解决方案的重大未得到满足的需求，并解决了相互交织的形式的耻辱和不平等，以改变高度脆弱的高危青年人口的心理健康结果。

Revised Abstract Transgender and gender diverse (TGD) youth (ages 15-24), with gender identities differing from their sex assigned at birth, are a growing NIH-designated health disparities population. TGD youth suffer higher rates of suicide than their cisgender counterparts; over half contemplate suicide in their lifetime. These and other health disparities are compounded for TGD youth who are Black or Hispanic and experience both gender- and racebased stigma and minority stress. Black adolescents are also at an increased risk of suicide; attempts increased 73% from 1991 to 2017. Interventions are needed urgently to improve the mental health of TGD youth, particularly TGD youth who are also racial minorities. We propose a transformative, multi-level intervention to advance equity and reduce health disparities for TGD youth through individual, interpersonal, systemic, and community-based changes that increase knowledge and support among providers, youth, and caregivers, thereby reducing suicidality and improving mental health. Provider and family/caregiver support are known to be critical determinants of mental health outcomes for TGD youth, yet no large-scale interventions exist to address these remediable structural and social determinants of health. Our intervention has two components. The first is a provider training and support program. This entails a free online training course for continuing education credit that teaches providers how to support and communicate effectively with TGD patients and a provider network for increasing psychosocial support. The second is an interactive educational digital platform for TGD youth and caregivers. The digital platform provides expert-generated knowledge via educational modules and uses interactive features to promote communication and strengthen relationships between youth and caregivers. We will use a Multiphase Optimization Strategy (MOST) framework to optimize the platform for testing in a hybrid effectiveness-implementation trial with an Immediate Arm (upfront access) and Deferred Arm (access at 6 months). The intervention period for each Arm will last 6 months, followed by an observation period of up to 12 months with continued access. Using validated subscales, we will assess changes in the proportion of individuals reporting suicidal ideation in the prior three months (primary outcome) and in psychological distress and anxiety, caregiver support, and health care empowerment (secondary outcomes), as well as dose effects, heterogeneity of treatment effects across groups, and within- group resilience factors. This innovative, multi-level intervention fulfills a significant unmet need for near-term and sustainable solutions to the health disparities faced by TGD youth and addresses intersecting forms of stigma and inequity to transform mental health outcomes for a highly vulnerable, at-risk youth population.