Developing a Conceptual Framework for Post-Incarceration Care for Sexual and Gender Minoritized Adults: A Concept Mapping Study

Abstract

Mass incarceration in the United States is a social-structural driver of health, including HIV, for sexual and gender minoritized adults (SGMA). The aim of this study was to develop a conceptual framework for post-release healthcare to use in adapting a mobile health unit (MHU) for SGMA returning from jail. We used concept mapping to develop a conceptual framework to answer a focal prompt regarding health-related needs for SGMA post-release. We recruited SGMA with recent incarceration experience and relevant community partners to participate in 4 concept mapping sessions: Brainstorming, Sorting and Rating, Interpretation Session 1, and Interpretation Session 2. Multidimensional scaling produce a two-dimensional point map of all statements and their relative relationships and hierarchical cluster analysis illustrated clusters of needs. SGMA community members (n=16) and community partners (n=13) generated 109 unique statements describing post-release healthcare-related needs for SGMA. Participants sorted and rated these items, creating a map of 10 clusters of needs: Physical Health, LGBTQ-Affirming Mental Health Care, Release Planning, Release Aftercare, Peer Support, Immediate Needs, Stabilizing Needs, Resources to Thrive, Access to Education, Structural Healthcare Advantages. HIV prevention and treatment were identified by participants as being both the most important and the best fitting for a post-release MHU intervention for SGMA. The vast majority of post-release healthcare needs identified by SGMA related to other social and structural drivers of health to reduce stigma and risk, increase access to important health services like harm reduction and gender-affirming care, improve their economic conditions, and provide social support and safety. This participant-led conceptual framework provides insight regarding important components to include in development and adaptation of interventions to address HIV and other health inequities for SGMA produced and exacerbated by the CLS. Prioritizing SGMA with CLS lived experience as research collaborators is critical in this work.

Introduction

The high rate of incarceration in the United States (US) is a social-structural driver of health and health inequities, particularly for marginalized populations like sexual and gender minoritized adults (SGMA).^{1, 2} The incarceration rate of lesbian-, gay-, and bisexual-identified people is approximately 3 times higher than the general incarceration rate in the US (1882 and 612 per 100,000, respectively).³ Similar overrepresentation trends are evident for transgender persons, particularly transgender women (16% to 65% compared to 3% for the general population).⁴ Incarceration for all populations is associated with a higher prevalence of infectious diseases (e.g., HIV, hepatitis C); chronic conditions (e.g., hypertension and diabetes); substance use disorders; and mental health disorders.^{2, 5, 6} HIV is a predominant health inequity for SGMA with criminal legal system (CLS) experience. Individuals involved in the CLS are at an increased risk of HIV acquisition and face unique challenges to HIV care linkage and engagement.^7–11 The HIV rate among formerly incarcerated adults ranges from 3 to 15 times the rate in the general population,¹² and Black men who have sex with men and Black transgender women living with HIV also have a high frequency of contact with the CLS.^{13, 14} Multiply marginalized groups such as populations with racial, sexual, and/or gender minoritized identities experience significant barriers to health equity.

SGMA experience unique health-related mistreatment while incarcerated that contributes to negative health outcomes.^15–19 Stigma related to SGM identity and behavior is known to increase SGMA victimization while incarcerated²⁰ and additional social psychological processes related to stigma and discrimination while incarcerated may lead to adverse health effects among incarcerated SGMA. Transgender adults have particularly high risk of victimization while incarcerated, including harassment and violence.¹⁸ Of particular concern is that while incarcerated, transgender adults are also known to experience lack of access to gender-affirming care (i.e., hormone therapies) and increased exposure to solitary confinement, a condition associated with an increase in adverse mental health outcomes (e.g., depression, self-harm, suicidality).^{15, 16, 21} Black SGMA who are incarcerated likely experience compounding effects of enacted racist homophobia and transphobia, increasing risk for victimization and negative health outcomes such as elevated rates of HIV.²²

HIV health disparities are particularly salient for this population. For many persons with HIV (PWH), the time immediately following detention represents a high-risk period for discontinuation of antiretroviral therapy (ART) and insufficient linkage with community-based HIV care. Competing priorities including securing housing and employment, reinstating health insurance, and managing requirements resulting from CLS contact (e.g., attending court appointments) are challenges to seeking out and engaging in HIV related medical care.^23–25 Thus, the post-release period must be prioritized for intervention to sustain HIV care services as well as other structural and social determinants of health for SGMA.

Negative health outcomes associated with CLS contact, including HIV, can be exacerbated during the post-release period. One study found the number of participants who self-reported fair or poor health increased during the year after release compared to when incarcerated;²⁶ another study found a high risk for death after release from prison, particularly during the first two weeks.²⁷ In addition to opioid overdose, the leading cause of death in the immediate post-release period, the most common causes of death post-release are cardiovascular disease and cancer, with viral hepatitis leading infectious disease deaths.²⁸ Structural vulnerabilities drive SGM-related stigma and discrimination during the post-release period, including exclusion from housing, employment, and healthcare, contribute to poor linkage to care post-release and are associated with discontinuity of medical care.^{16, 29}

Innovative healthcare models have emerged to address common barriers and facilitators to post-release health services engagement for individuals leaving detention settings.^{30, 31} Interventions demonstrating post-release improvements in HIV care outcomes for PWH reentering their communities include functional support (e.g., appointment scheduling, attendance support) and contextual support (e.g., social support), and frequently leverage navigators or community health workers.^{32, 33} However, persistent gaps remain in models that support SGMA needs specifically.³⁴ One randomized controlled trial that piloted an adapted reentry intervention for currently incarcerated transgender women highlighted the importance of peer facilitators, linkage to community resources that affirm gender identity (i.e., gender-affirming), and programmatic buy-in from jail staff.^{32, 33} Work from this group has identified gaps in services for SGMA reentering their communities from jail, including SGM-inclusive mental health treatment, HIV prevention and care, housing options, substance use treatment and harm reduction services, job opportunities, and assistance with legal support, access to gender-appropriate clothing and wigs, and SGMA support groups.¹⁶ Incorporating transportation and/or transportation benefits into post-release programs could relieve one of the largest barriers to successful reentry.³⁵

One existing model in a setting culturally and geographically similar to Cuyahoga County where our study took place is the Rethinking Incarceration and Empowering Recovery (RIvER) Clinic in Pittsburgh, Pennsylvania. RIvER provides immediate access to primary care services including HIV care, substance use treatment, overdose prevention, as well as social services and support. RIvER is comprised of a multidisciplinary, community-centered team including clinicians, social workers, community health workers, and peer specialists. Within its comprehensive, multimodal clinic, RIvER model utilizes mobile health unit (MHU) clinic services offered outside of the jail, as well as community health workers embedded in the jail to support transition from jail to the community by linking individuals to RIvER upon release. From June 2021 to December 2022, RIvER provided pre-release services to 602 individuals (during detention) and received more than 550 referrals for post-release care. The RIvER team successfully connected with 60% of referrals, resulting in improved linkage to post-release substance use treatment, low rates of fatal overdose among their clients with opioid use disorder (<3%; less than national estimates³⁶), reduced recidivism, and long-term service engagement.³⁰ While the use of a harm reduction-focused MHU to provide access to healthcare services in different locations addresses known barriers, how well the MHU impacts HIV prevention and care is unknown and services are not tailored to SGMA’s needs. Adapting and tailoring the RIvER MHU for SGMA with CLS contact may improve post-release care, linkage to care, and HIV prevention and care continuum outcomes.

There is no known conceptual framework for post-release healthcare for SGMA to be applied to intervention development, adaptation, and testing. To effectively adapt existing interventions, like RIvER, for SGMA during post-release, community-identified needs, priorities, and barriers and facilitators are critical to understand to integrate into intervention adaptation and implementation strategies. Incorporating populations with CLS contact into the development, implementation, and evaluation of post-release interventions is necessary to ensure programmatic success.^{37, 38} Developing a framework to address barriers and leverage strengths of SGMA with CLS contact to optimize structural and social determinants of health is vital for improving post-release healthcare, including HIV prevention and care outcomes, for SGMA.

The aim of this study was to use Concept Mapping, a structured, community-engaged research method, to develop a conceptual framework for post-release healthcare, including HIV-related prevention and care for SGMA. Based on the development of this framework, we have adapted the RIvER MHU to meet the unmet health-related needs of SGMA returning to their communities from carceral settings to improve HIV prevention and care. This paper describes the process of partnering with the community to elucidate critical components of post-release healthcare for SGMA that informed the adaptation and pilot project.

Methods

Setting and Community Partner

All research was conducted in Cuyahoga County, building on established partnerships between the University of Pittsburgh and Case Western Reserve University via the Rustbelt Center for AIDS Research Ending the HIV Epidemic Scientific Working Group. In 2023, the Cuyahoga County Jail recorded 20,312 total bookings with an average length of stay of 30 days, including stays that lasted less than one day.³⁹ In 2019, Cuyahoga County reported 158 new diagnoses of HIV (12.8 per 100,000 population), an increase from the EHE baseline year (2017).⁴⁰ Men who have sex with men (MSM) and MSM from minoritized groups are two populations that experience elevated HIV incidence in Cuyahoga County; racial HIV disparities are also significant with Black individuals having a rate of new HIV infection more than 6 times higher than white individuals.⁴¹ Thus, there is high need in this setting to address post-release care for SGMA that incorporates HIV prevention and care. To increase community engagement and prioritize the expertise of people with lived experience, we partnered with the Northeast Ohio Coalition for the Homeless. Northeast Ohio Coalition for the Homeless exists to eliminate the root causes of homelessness through advocacy, education, organizing, and street outreach,⁴² and has a long history of supporting individuals impacted by the CLS. The research team of two Multiple Principal Investigators, two Co- Investigators, and one Project Director included multiple people with CLS lived experience and multiple people with SGM identities. Brainstorming and Sorting and Rating sessions were conducted by the Project Director with SGM identity and qualitative data collection expertise, and the Interpretation sessions were conducted by the Co-Investigator with SGM and racialized identities, CLS lived experience, and strong trust and relationships with Black SGM communities in Cuyahoga County.

Concept Mapping Method

We used concept mapping, a structured, participatory, mixed-methods approach to research that supports community-led group data collection and analysis to develop a conceptual framework (i.e., a “map”) of a specified domain that visually represents a particular community’s views and priorities.^43–47 In partnership with University of Pittsburgh Concept Mapping Institute (CMI), we used concept mapping’s 6 steps (described below; Figure 1) to develop community consensus regarding healthcare-related needs of SGMA during post-release. Concept mapping participants with lived experience collaborated on conceptual framework development through 4 of the 6 steps, and the community partner provided guidance on all 6 steps, including development of the research questions and interpretation of results (i.e., the map). Due to the method’s highly participatory and collaborative nature, it is well suited to partner with SGMA to identify their healthcare needs post-release and explore how those needs interrelate. We used Concept System^® groupwisdom^™ software: Concept Systems, Inc. Copyright 2004–2024; all rights reserved (groupwisdom^™)⁴⁸ for analysis.

Figure 1.

6 Steps of Concept Mapping.

Sample and Recruitment

Our sample included SGMA with incarceration experience and community partners with experience providing services to this population to capture both lived experience and structural- and organizational-level factors. SGMA community members were eligible if they: 1) were 18+ years old; 2) were incarcerated in jail (≤5 years); 3) self-reported a sexual or gender minoritized identity; and 4) spoke English. Community partners were eligible if they: 1) were 18+ years old; 2) were affiliated with NEOCH or another community organization serving SGMA; 3) self-reported history of working with formerly incarcerated SGMA; 4) self-reported lived experience with criminalized behaviors, identities, or experiences (e.g., homelessness, arrest, police targeting, neighborhood surveillance); and 5) spoke English.

SGMA community members were recruited using passive strategies; Northeast Ohio Coalition for the Homeless and the study team distributed recruitment flyers with study information to other SGMA-serving organizations, and used snowball sampling strategies with enrolled participants. Community partners were drawn from community partnerships and Northeast Ohio Coalition for the Homeless, and were contacted via email and telephone. We continued recruiting through the first five steps to ensure appropriate and relevant representation from SGM experiences, with a target sample size of 25 participants (15 SGMA community members; 10 community partners). Some participants did not complete all sessions. All participants provided informed written consent before their first concept mapping session and completed a brief anonymous demographic questionnaire developed by the research team with expertise in SGMA and CLS community-based resesarch. All activities were approved by University of Pittsburgh Institutional Review Board.

Data Collection

Participant data collection occurred between January and May 2024, via in-person “sessions” at NEOCH (Table 1). We convened separate sessions with SGMA and community partners to prioritize SGMA community members’ comfort and safety when discussing sensitive topics. Transportation support was offered to all participants. All sessions were led by the Project Director and/or a Co-Investigator, with the former having SGM identity and qualitative data collection expertise and the latter having lived experience with criminalization and racialized SGM identity. All sessions were audio recorded, and field notes were written by the Project Director and/or an MPI. Sessions were professionally transcribed via TranscribeMe. Field notes were used to contextualize study transcripts as needed.

Table 1.

Concept Mapping Data Collection Methods and Outcomes

Session Name	Session Goal
Session 1: Brainstorming (October 2023)	• Generate a list of responses to the focal prompt (e.g., “What are the things trans and nonbinary adults need for healthcare when we come home from jail?”)
Session 2: Sorting and Rating (January 2024)	• Individually sort brainstormed responses into groups (“clusters”) that make sense to the participant • Individually rate each response on a 5-point Likert scale using ratings questions
Session 3: Interpretation Session I (March 2024)	• Interpret selected concept map and clusters to help researchers understand the story behind the clusters • Generate cluster titles to identify post-release healthcare components
Session 4: Interpretation Session II (May 2024)	• Review data visualizations (e.g., ratings maps, Pattern matches, Go-Zones) • Discuss community priorities for post-release healthcare for TNB adults

Preparation:

The research team, in collaboration with the University of Pittsburgh CMI and NEOCH, developed the following focal prompt (i.e., Step 1): “What are the things LGBTQ+ adults need for health and healthcare when we come home from jail?” This prompt was designed to elicit needs related to healthcare specifically and health generally during the period immediately following jail release for SGMA. This prompt does not specifically mention HIV, which was chosen to ensure that wider social determinants of health and other health-related needs were considered in the model.

Brainstorming.

Participants were asked to write brief responses on sticky notes, with one response per note. Participants could create an unlimited number of responses and were asked to work individually to protect minority views that might not emerge during group discussion.⁴⁵ Next, participants were invited to share and discuss one response with the group. Participants were encouraged to create more responses if the discussion prompted additional ideas. All sticky notes were anonymously collected. Two researchers (SLC; AR) discussed each response to ensure simple language, remove duplicates, and split double-barreled responses, and any conflicts were resolved with the entire research team. One statement was duplicated in the list (“contacting people in the jail prior to release”), resulting in 109 unique statements. Because the statement was duplicated in sorting and rating data collection and analysis, we chose to include the statement twice in the final list to reflect the map and list of statements participants reviewed and interpreted. The final list of items was uploaded to groupwisdom^™.

Sorting and Rating.

Using the final list of brainstormed responses (i.e., items) (see Results), participants individually rated each item using two rating questions developed in collaboration with the Universtity of Pittsburgh CMI and NEOCH using 5-point Likert scale response options: 1) “How important is this item for the health of LGBTQ+ adults when returning from jail?” (1: Not at all important, 2: Low importance, 3: Somewhat important, 4: Important, 5: Very important) to assess participants’ priorities and 2) “How well does this item fit a mobile van reentry clinic model for LGBTQ+ adults returning from jail?” (1: Not well at all, 2: A little well, 3: Somewhat well, 4: Well, 5: Very well) to assess how well participants felt each item fit the adapted intervention using an MHU. Next, participants sorted the items into groups (i.e., themes) based on how each participant conceptualized the items and their relationships. Participants were instructed to create between three and 15 groups with no groups being leftover items. Participants then named each group. Following these sessions, each participant’s clusters, cluster titles, and ratings were uploaded to groupwisdom^™.

Representation and Analysis.

Participant sorting data was first compiled into a similarity matrix to describe the frequency of statements being sorted together by participants.⁴⁵ We then used multi-dimensional scaling, a technique to visualize data across a distance matrix, to produce a two-dimensional point map of all statements and their relative relationships.⁴⁵ The point map used distance between points (i.e., brainstormed items) to represent the frequency of points being sorted together. Points visually close together were generally sorted more frequently compared to points displayed farther apart, indicating a stronger relationship.⁴⁵ Using the point map and hierarchical cluster analysis, we created a range of cluster maps displaying non-overlapping “clusters” of points on the point map; with no mathematical criterion to selecting the best map,⁴⁵ the study team and NEOCH selected the most salient map that displayed meaningful and interpretable clusters, which is a standard practice in concept mapping. Using the selected cluster map and participant ratings, groupwisdom^™ generated multiple representations to visualize SGMA community views, including: 1) Ratings maps, or maps that visualize which statements or clusters were rated most important or best fitting; 2) Pattern matches, or reports that compare ratings of clusters between rating questions (e.g., importance versus model fit); and 3) Go-zones, or rating comparisons within clusters visualized on a matrix that highlights, for example, most important and best fitting statements within a cluster.^{43, 45}

Interpretation.

Next, we conducted two focus groups with each participant group (n=4). The goals of the first sessions were to 1) discuss and contextualize the selected concept map, including positive, negative, and missing elements, 2) interpret and explain all clusters to provide context and meaning, and 3) finalize the name of each cluster. The goals of the second interpretation session were to 1) review additional data visualizations, 2) discuss community priorities for core components of an adapted post-release intervention for SGMA, and 3) brainstorm logistics for an adapted intervention (e.g., times and locations of service), branding and, and additional community collaborators.

Utilization.

The primary purpose of this concept mapping work was to develop a conceptual model of post-release healthcare for SGMA to be used to adapt an intervention for pilot testing in Cuyahoga County. The primary method of utilization of concept mapping results was incorporating prioritized items into post-release MHU intervention adaptation elements and strategies.

Results

Study Sample

A total of 29 participants (n=16 SGMA community members and n=13 community partners), completed at least one concept mapping activity (Figure 2); not all participants completed all activities. Approximately 43% of our sample identified as transgender or nonbinary (Table 2). Most participants across both groups identified as Black or African American (78%), with over 20% of participants identifying as more than one race. Close to half (48%) of participants received $500 or less in the last month. Over a third of participants had a high school education or less (37%). Of SGMA community members, the majority of participants had been incarcerated 2–5 times, with 4 participants having been incarcerated over 20 times. Nine of 16 SGMA community members were living with HIV.

Figure 2.

Participant Flow Chart.

Table 2.

Participant Characteristics of the Total Sample

	Total
Characteristic	N	(%)
Total Observations, Row Percentage	29	(100.0)
Gender
Female/woman/girl	4	14%
Male/man/boy	12	41%
Transgender female/woman/girl	7	24%
Transgender male/man/boy	4	14%
Genderqueer, or not exclusively female or male	1	3%
Sex Assigned at Birth
Female	9	31%
Male	19	66%
Sexual Orientation *
Lesbian or gay	11	38%
Straight or heterosexual	8	28%
Bisexual	5	17%
Queer	2	7%
Pansexual or something else	2	7%
Age (years), mean (standard deviation)	39.0	10.76
Race/Ethnicity *
Black or African American	21	72%
White	6	21%
Native American/Alaska Native	2	7%
Native Hawaiian or Other Pacific Islander	1	3%
More than one race	6	21%
Monthly Income
Greater than $2000	10	34%
$1001 to $2000	2	7%
$501–$1000	2	7%
$0–$500	13	45%
Education
Less than High School	1	3%
High School Degree or Equivalent	9	31%
Some College but No Degree	6	21%
Associate or 2-Year Degree	5	17%
Bachelor’s Degree	5	17%
Any Graduate Education	1	3%
Incarceration History **
1 time	2	13%
2–5 times	9	56%
5–20 times	2	13%
20+ times	4	25%
HIV Status **
Living with HIV	9	56%
Not Living with HIV	7	44%

Notes. Some particpants did not answer all questions.

^*Participants could select more than one option for race and sexual orientation.

^**Only SGMA completed incarceration history and HIV status questions (n=16).

Brainstorming Results

Participants (n=22) generated a list of 185 responses to the focal prompt (i.e., “What are the things LGBTQ+ adults need for health and healthcare when we come home from jail?”). Response examples included HIV medicine, PrEP, access to mental health services, harm reduction kits, contacting people in the jail prior to release, healthcare navigation assistance, housing information, and transportation assistance. The final list included 109 unique items, which were used for the Sorting and Rating session (Table 3).

Table 3.

Clusters and Statements with Mean Participant Ratings

Cluster Title	Statement Number	Statement	Importance Rating	Model Fit Rating
Physical Health			4.08	4.01
	5	Blood tests for illness other than STI	4.80	4.32
	9	Pregnancy screenings	3.10	3.23
	19	Risk awareness education	3.50	3.77
	21	STI treatment	4.20	4.32
	22	Safe sex tools	4.10	4.00
	28	STI testing	4.45	4.36
	36	Hormones	3.65	3.19
	38	Condoms	4.05	3.90
	45	Access to tools for pregnancy prevention	3.25	3.36
	46	HIV tests	4.75	4.64
	48	HIV medicine	4.90	4.64
	49	COVID tests	3.85	3.50
	50	Social determinants of health screening (social determinants of health mean non-medical factors that affect health, like housing, income, access to food, discrimination)	3.55	3.86
	72	Access to testing	4.30	4.27
	81	Health screenings	4.35	4.55
	83	PrEP	4.40	4.27
LGBTQ-Affirming Mental Health Care			3.90	3.63
	7	Needle exchange	2.95	3.14
	12	Gender affirming prosthetics	3.20	3.36
	13	Gender affirming mental health care	4.25	3.55
	17	Connection to LGBTQ+ groups	3.95	4.00
	32	Transgender support	4.30	3.59
	39	Peer support	3.95	3.45
	40	Group therapy	3.68	3.32
	47	Medical transition support	3.95	3.73
	80	Therapy	4.20	3.95
	93	Access to mental health services	4.60	4.19
Release Planning			3.93	3.46
	1	Follow-up appointments scheduled before release	4.70	3.77
	2	Building connections with healthcare providers in the jail	3.95	3.18
	3	Provider contact with individual while in jail	3.84	3.32
	6	Access to substance use services	4.05	3.43
	8	Harm reduction kits	3.45	3.77
	16	Access to harm reduction	3.37	3.68
	41	Individual therapy	4.26	3.50
	88	Support groups	3.80	3.00
Release Aftercare			3.87	3.70
	4	Contacting people in the jail prior to release	3.60	3.55
	54	Transition plan prior to exit	3.68	3.32
	57	Community spaces for trans women, especially Black trans women	4.05	3.59
	70	Access to transportation to appointments	4.10	3.73
	85	A hug	3.50	4.09
	102	Contacting people in the jail prior to release	3.74	3.52
	103	Support with reconnection to prior providers and services	3.95	3.76
	106	A ride from jail	4.37	3.90
	110	Peer support on release date	3.83	3.85
Peer Support and Navigation			3.44	3.55
	10	Assessment of emergent needs	3.70	3.91
	18	Peer support technology app	3.00	3.50
	30	Social support	3.50	3.68
	43	Healthcare navigation assistance	3.40	3.82
	53	Nothing for us without us	2.90	2.91
	69	Access to peer support	3.60	3.59
	75	Support for experiences of abandonment	3.00	2.55
	79	Safe spaces	4.40	4.41
Immediate Needs			3.66	3.50
	26	Hair cuts	2.45	2.82
	27	Clothing vouchers	3.70	3.82
	31	Obama phones	3.30	3.23
	35	Housine information	4.40	4.60
	37	Clothing	3.70	3.40
	58	Transitional housing	4.35	3.59
	59	Employment opportunities	4.25	3.82
	82	Housing	4.65	4.09
	108	Caffeine (e.g., energy drinks, coffee)	2.17	2.10
Stabilizing Needs			3.52	3.36
	14	Access to stable mailing address to receive documents	3.90	3.29
	20	Housing resources	4.40	4.64
	33	Food assistance	4.40	4.50
	34	Hygiene products	4.15	4.27
	52	Transportation assistance	3.95	3.95
	84	Gender-affirming clothing	3.45	3.05
	86	3-months paid cell phone	3.65	3.45
	87	Furnished apartment	3.45	3.23
	91	Vape pen	1.95	1.68
	92	Cigarettes	1.70	1.77
	105	Place with an open bed	3.68	3.43
	107	Bedding (e.g., pillow, blanket)	3.53	3.10
Resources to Thrive			3.49	3.54
	23	Job resume assistance	3.85	3.59
	24	Quick job opportunities	4.00	3.64
	29	Wigs	2.00	2.38
	44	Information on LGBTQ+ community resources	3.90	4.18
	51	Co-location for benefits assistance (e.g., food stamps, Medicaid, identification)	3.50	3.91
	60	Resource navigation	3.55	3.81
	61	Job training	3.89	3.23
	62	Case management	4.05	3.91
	66	Register to vote	3.50	3.29
	78	Information on where to go	3.90	4.23
	98	Education on how to be an advocate after release	2.85	2.86
	109	Reentry FAQ sheet created by people with lived experience	2.89	3.48
Access to Education			3.36	3.20
	25	Access to school	3.45	3.27
	42	Access to education	3.45	3.19
	56	Access to information for trans adults	3.90	4.14
	63	Family education	3.37	2.91
	64	Community education	3.45	3.36
	67	Diversity, equity, and inclusion (DEI) training	3.15	3.33
	73	Policy change	3.10	2.64
	74	Education to debunk myths	2.55	2.32
	77	Information	3.50	4.05
	94	Education on the impact of criminalization on access to programs/services	3.70	3.24
	97	Education on LGBTQ+ spiritual services	3.30	2.71
Structural Healthcare Advantages			3.82	3.60
	11	Access to prescription discount plan	4.15	3.55
	15	Expungement clinics	3.45	2.77
	55	Access to healthcare for trans adults	4.35	4.09
	65	Healthcare policy change	3.25	2.95
	68	Healthcare education	3.70	3.73
	71	Access to gender-affirming care	3.50	3.91
	76	Stigma reduction	3.25	3.05
	89	Clinic hotline for information and help	3.53	4.05
	90	Healthcare provider knowledge of healthcare needs across the LGBTQ+ spectrum	4.05	3.77
	95	Trauma-informed care	3.90	3.52
	96	Access to free health services	4.50	4.19
	99	Clinic staff trained in mental health first aid (mental health first aid means assisting people out of crisis)	3.70	3.45
	100	HIV education	4.32	4.05
	101	Make changes to healthcare policies	3.42	2.71
	104	Linkage to LGBTQ+ clinics	4.21	4.14

Concept Map and Clusters

The point map (Figure 3) using Sorting and Rating data from participants (n=23) had a stress value of 0.3074 on a range of 0–1, indicating strong goodness of fit. After reviewing the three- to 15-cluster concept maps the research team and NEOCH selected the 10-cluster map as the clearest, most salient depiction of post-release care for SGMA (Figure 4). During the first Interpretation session, participants: 1) reviewed and provided feedback on the groupwisdom^™-generated cluster titles, 2) brainstormed new cluster titles that best captured the meaning of each cluster based on a review of the items within a cluster, 3) described each cluster, and 4) provided insight into cluster-item relationships. The final participant-generated titles were selected by the study team. We describe each cluster below:

1. Physical Health: This cluster included prevention needs like HIV tests, STI tests, pregnancy screenings, blood tests for illness other than STI, COVID tests, and social determinants of health screenings (e.g., housing, income, food access). Additional health-related items like PrEP, HIV medicine, safer sex supplies, access to hormones, and risk awareness education were included in this cluster. Participants interpreted this cluster to be highlighting the need for physical health prevention, care, and risk awareness.

2. LGBTQ-Affirming Mental Health Care: Many mental health-related items were grouped together in this cluster, including gender-affirming mental healthcare, connection to LGBTQ+ groups, peer support, therapy, and medical transition support. Participants suggested that needle exchange and gender-affirming prosthetics are vital to SGMA mental health and within the scope of post-release healthcare for SGMA.

3. Release Planning: Considering pre-release planning within the context of post-release healthcare was of particular interest to participants. Participants reported that connecting with SGMA on the inside prior to release, scheduling follow-up appointments in the community before release, and access to substance use services and mental health support prior to and during release are essential, if atypical; one participant reported that when he was released, “They just shoved me out the door,” without any support in place or information regarding post-release services.

4. Release Aftercare: Items like transition plan prior to exit, access to a ride from jail, support with reconnection to prior providers and services, and peer support on release date highlight the need for support during and immediately following detention release. Participants noted the need for community spaces and support for Black trans women during this time. Of note, a hug was included in this cluster, with participants highlighting the importance of human connection to release and release aftercare.

5. Peer Support: This cluster was viewed by participants as being an “essential” component of post-release healthcare for SGMA, evidenced by its central location on the map indicating its strong relative relationships with all other clusters. Social support (i.e., support by peers with criminalization and LGBTQ+ lived experience) and safe spaces for SGMA during post-release were highlighted during Interpretation sessions. Participants also highlighted the phrase “Nothing for us without us” during Interpretation and as an item during Brainstorming, noting the importance of including SGMA with CLS contact in intervention development and planning. Likewise, healthcare navigation assistance, the most central individual point on the point map, was considered key by participants.

6. Immediate Needs: This cluster focused on post-release needs that were crucial in the short term. For example, haircuts, gender-appropriate clothing, housing and housing information, and even caffeine and energy drinks wre described as providing safety and comfort for SGMA who have just been released from incarceration. Some participants believed this cluster focused on “personal” needs and stability.

7. Stabilizing Needs: Items were interpreted as stabilizing the individual post-release, including food assistance, hygiene products, transportation assistance, paid cell phones, and accessible housing and bedding. Participants highlighted the general overlap between this cluster and the “Immediate Needs” cluster (cluster 6), noting that the two could be grouped together conceptually as one theme focused on short-term post-release needs. Participants felt the conceptual differences between these clusters were minor and irrelevant.

8. Resources to Thrive: Items grouped in this cluster were viewed as ongoing resources that helped SGMA “thrive” during post-release. Participants included job resume assistance, information on LGBTQ+ community resources, co-location of benefits assistance (e.g., food stamps, Medicaid, identification), case management, voter registration, and other training and navigation of services in this cluster. These were viewed as critical and conceptually different from the immediate needs described above.

9. Access to Education: Items in this group included those related to access to informational resources for individuals who have been incarcerated, their loved ones, and communities, as well as access to school and training. While education and information were broadly defined, participants provided the following specifications: education on CLS issues, SGMA health and experiences, and intersecting experiences of criminalization, SGM identity, and racialized identity. Policy change is also broadly included in this cluster, although quite close visually and conceptually to cluster 10, illuminating the importance of including policy-level work in our conceptual models for healthcare to improve access to education.

10. Structural Healthcare Advantages: This cluster highlighted the need for ongoing healthcare for SGMA that is gender-affirming, trauma-informed, free, and LGBTQ-competent. Participants included stigma reduction, healthcare education, and healthcare policy change in this cluster, and generally felt that this cluster represented structural healthcare policies, practices, and access that must be addressed and included in tandem with other clusters in the concept map.

Figure 3.

Point Map Displaying Items and their Relative Relationships

Figure 4.

10-Cluster Map with Titles

Data Visualizations

The Pattern Match (Figure 5) indicated that Physical Health was both the most important concept for post-release healthcare and the best fitting concept to incorporate in an adapted MHU clinic model. Release Aftercare and LGBTQ-Affirming Mental Health Care were also rated highly for both. While Release Planning was ranked second highest for importance, this cluster dropped significantly lower for model fit, reflecting the current challenges of pre-release planning and the needs to address these barriers. Structural Healthcare Advantages was rated higher than many other clusters related to immediate needs, which highlights the participants’ desire to include structural healthcare access, education, and policy into post-release healthcare interventions.

Figure 5.

Go-Zone of Mean Participant Ratings of All Items

In the Go-Zone (Figure 6), the statements with the highest average ranking for importance and fit were HIV medicine, HIV tests, emphasizing the importance of integrating the HIV prevention and care continuum into post-release care for SGMA. Other items in the “go-zone” green quadrant with high importance and fit were blood test for illness other than STIs, housing resources, housing information, food assistance, safe spaces, STI testing, access to free health services, and follow-up appointments scheduled prior to release.

Figure 6.

Pattern Match of Mean Cluster Ratings

Discussion

Participants in this study identified a wide range of factors important to consider in post-release healthcare intervention development and adaptation work for SGMA. SGMA with CLS lived experience and community partners developed a conceptual model for post-release care that included physical and mental healthcare, care that is affirming of SGM people, peer support and healthcare navigation, release planning and aftercare, and social determinants of health like housing support, job assistance, and food security. HIV prevention and treatment were identified by participants as being both the most important and the best fitting for a post-release MHU intervention for SGMA; this highlights that prioritizing HIV prevention and care in post-release settings is in line with community needs. Even so, out of 109 items, only 3 were HIV-specific (e.g., HIV education, HIV tests, HIV medicine). While not all participants were living with HIV, the vast majority of post-release healthcare needs identified by SGMA related to other social and structural drivers of health to reduce stigma and risk, increase access to important health services like harm reduction and gender-affirming care, improve their economic conditions, and provide social support and safety. We know that in order to improve access and engagement in HIV prevention and care we must also address social and structural drivers of health.⁴⁹ This conceptual framework calls attention to the need for post-release interventions for SGMA, including HIV-focused interventions, to provide services that are comprehensive, safe, and inclusive.

Of note, rather than one cluster highlighting the concept of gender-affirming care, gender affirmation was diffused throughout the conceptual model and included in multiple clusters. Cluster 2, “LGBTQ-Affirming Mental Health Care,” highlights participants’ belief that all mental health services should be SGM-affirming and provide specific, affirming support for SGMA that includes gender affirmation such as gender affirming mental healthcare, transgender support, and medical transition support. Gender affirmation is also specifically included in 5 other clusters. While incarcerated, SGMA experience a profound lack of gender affirmation via housing placement based on sex assigned at birth, lack of access to gender-affirming medications and surgeries, gender-based violence victimization and other mistreatment, and removal of gender-affirming clothing and other accessories.¹⁶ The need for gender affirmation and gender-affirming care within post-release interventions is significant; participants specifically identified access to information for transgender individuals, access to gender-affirming care, general access to healthcare for transgender adults, access to gender-affirming clothing and wigs, and community spaces for transgender people, especially Black transgender women, as important factors to consider and include when adapting post-release interventions for SGMA. These results emphasize the need to prioritize gender affirmation and the needs of transgender people when developing and adapting post-release interventions. Our results are in line with Sevelius et al.’s pilot randomized controlled trial of an adapted reentry support intervention for transgender women incarcerated in a county jail, which found that facilitated referrals to gender-affirming community resources were crucial to programmatic success.⁵⁰

Participants emphasized the importance of targeted structural components to healthcare such as HIV and other healthcare education, stigma reduction, and healthcare policy changes that better support SGMA health (Cluster 10 “Structural Healthcare Advantages). Among other post-release healthcare concepts that are more specific, individual, and immediate, participants perceived policy-, education-, and access-level changes to be vital to the long-term improvement of SGMA health post-incarceration. Policy reform to improve access to education, healthcare, and gender affirmation, as well as the reduction of stigma for SGMA and people who have CLS contact, must be explored and implemented. Even so, we see policy changes limiting access to education, healthcare, and gender affirmation, as well as increasing stigma of SGM identities and criminalization, on the rise across the United States, particularly policy changes targeted transgender adults and youth through restrictions of gender-affirming care and research.^{51, 52} Such policy changes and limiting vital healthcare services for marginalized communities may further deepen health inequities, including HIV and other infectious diseases, negative mental health outcomes, and other health conditions associated with stigma and discrimination.^{51, 53}

Many participants called attention to the emergent time-bound quality of the conceptual framework and the importance of connecting with SGMA prior to release from incarceration. Two of the 10 clusters contained a time element to how they were sorted and related to incarceration release: “Release Planning” and “Release Aftercare.” While participants acknowledged significant barriers to release planning in county jails, where individuals are often released without notice and in the middle of the night, they insisted that every effort should be made to develop processes for immediate access to post-release interventions upon release. Doing so has the potential to bridge the gap between healthcare while incarcerated and healthcare after release, or to provide healthcare after a CLS-created healthcare disruption during incarceration. Strategies like the Transitions Clinic Network have shown some promise for immediate post-release linkage to care and should be further explored fo their impact on SGMA.^{54, 55}

Additionally, some clusters identified needs that were distinguished by their immediacy, such as “Immediate Needs” versus “Stabilizing Needs” versus the more long-term concept of “Resources to Thrive.” It may be important to consider changes in needs on a continuum beginning with incarceration and extending through long-term release when developing and adapting post-release interventions for SGMA. Something as simple as haircuts was considered an immediate need, indicating the importance of identifying and addressing individual priorities for SGMA within post-release interventions. Some participants could not easily distinguish between these three clusters, however; future research is needed to further develop post-release timelines for care and identify opportunities to implement healthcare strategies and support at different points in time.

This study has several limitations worth noting. Our non-probability sampling strategies and focus on Cuyahoga County limits the generalizability of findings. Our sample is missing important Latinx, Indigenous, and Asian representation, which limits our knowledge of the unique post-release needs of these SGMA subpopulations. Despite this, our study has many relative strengths. Our study has strong representation across the SGM spectrum (i.e., gay, lesbian, bisexual, transgender, nonbinary), including many Black and mixed-race participants, which broadly reflects the racial and ethnic disparities in the carceral population in Cuyahoga County and the United States.⁵⁶ Our community partner with SGM identity, CLS expertise, and strong community relationships guided and supported all 6 steps of data collection and analysis. Participants provided strong positive feedback about their research experiences, including excitement regarding the final concept map and ideas for an adapted MHU intervention for SGMA in Cuyahoga County.

Conclusions

This research represents a critical first step in the development of post-release healthcare interventions for SGMA. The conceptual framework for post-release care developed by SGMA with CLS experience provides insight regarding important components to include in development and adaptation of interventions to address health inequities for SGMA produced and exacerbated by the CLS. Importantly, this framework also illuminates how reentry models can more effectively center HIV prevention and treatment, highlighting the need for targeted HIV testing, timely linkage to PrEP or HIV care, continuity of medications, support for social structural drivers of health, and culturally grounded support that reflects the heightened HIV vulnerability faced by SGMA during the post-release period. While developing and adapting interventions to pilot at the local level is the first step to scaling up systems-wide approaches to care and support for this population, our findings also may be used to influence policy recommendations to improve the health and wellbeing of SGMA returning to their communities. For example, prioritizing the voices of SGMA with CLS lived experience as research collaborators is critical in this work.