This article is part of State of Health, a series examining integrated care and its potential to improve Michiganders' health. It is made possible with funding from the Michigan Health Endowment Fund.

Throughout its 20 years in existence, Detroit's Ruth Ellis Center has set its direction based on feedback from the homeless LGBTQ youth it serves. As a result, what began as a drop-in center has evolved into a community where youth can access a full circle of services – including the Ruth Ellis Center Health and Wellness Center, an integrated primary and behavioral health clinic opened in 2017.

Ruth Ellis Center.

Jerry Peterson, the center's executive director, asserts that offering integrated healthcare was essential, as 80-90% of the 500 youth the center serves each year did not have a health home. Since the clinic opened, approximately 400 of those youth have established their health home at the Ruth Ellis Center.

"Never in their lives have they had an established place with records where they could get services. That's a dramatic step forward, [to have medical and behavioral health care] colocated with basic needs services," Peterson says. "They come here for an appointment, hang out with friends, and access all their basic needs — a hot meal, clothing, showers, laundry. They can do all of that in one place, in one day."

In 2015 the center launched a $1.5 million capital campaign to construct the clinic. The Michigan Health Endowment Fund, Hope and Grace Initiative, The McGregor Fund, The Jewish Fund, and Community Foundation for Southeast Michigan all contributed to the project.

"Our original mission was to provide short- and long-term residential safe space and support services for runaway homeless and at-risk lesbian, gay, bi-attractional, transgender, and questioning youth. We've really expanded that," Peterson says. "The new mission is youth-driven, from a young person's perspective. It's to create opportunities with LGBTQ young people to build their vision for a positive future."

Primary and behavioral services

In partnership with Henry Ford Health System, the clinic provides general medical primary care in addition to specific services geared to its patient population. Those may include gender affirming hormones, preventive HIV prep, HIV treatment, reproductive health, and inclusive, comprehensive sex education. The medical staff includes two physicians, a nurse practitioner, a nurse, a medical assistant, an HIV case manager, and an early intervention specialist, who connects people with HIV to treatment.

Dr. Maureen Connolly, Ruth Ellis Center's pediatrician and medical director of Henry Ford Health System's School-Based and Community Health Program, says that broad range of services is important. She notes that mainstream providers often narrowly focus on HIV when they're seeing a trans patient, rather than taking the broader approach that they would with a heterosexual patient.

"The young people I've seen have shared with me that the only time they would see [a doctor] would be specifically in regard to HIV," Connolly says. "Physical health is so much more than that. There are so many more aspects of wellness, wellbeing, and their own personal goals for wellness. … It's not just this one thing we're thinking about. It's about them being able to reach their own health goals."

The center's integrative health approach also includes groundbreaking behavioral health programming, led by three therapists. In addition to traditional outpatient therapy sessions on site, the center offers a home-based, family-focused family preservation program. In that program, a practitioner works with a young person's entire family, focusing on how the young person's feeling of acceptance or rejection at home impacts their health outcomes.

"They help move the family to incorporate the support and acceptance that the young person needs," says Katie Gorney, Ruth Ellis Center's behavioral health director. "It allows for tailoring to each individual family, attuned to their beliefs and culture."

Through the center's restorative justice program, one therapist supports LGBTQ youth in the court system, whether they are on probation or placed in a residential facility. Recognizing that many of these youth are disproportionately represented in the prison system, this program takes a transformative justice approach that emphasizes prevention, rehabilitation, accountability, counseling, and education instead of retribution. In the near future, the center will hire an additional clinician to facilitate a behavioral health program focusing on queer and lesbian women and their families.

"Research does support that LGBTQ people have higher rates of mental health concerns. Part of that [is caused by] the discrimination and prejudice they face, the trauma and the impact," Gorney says. "We know that the risk is there because of that added layer, but it's not necessarily the case for everyone."

Dwayne Cole came to the Ruth Ellis Center as a client at age 18. After progressing through the center's peer-leadership pipeline, he accepted a position as its drop-in services manager. Having interacted with the center as both client and provider, he says the clinic is making a great difference for Detroit's LGBTQ youth.

Dwayne Cole at Ruth Ellis Center.

"I feel like integrating medical and behavioral health had a huge impact," Cole says. "It made the Ruth Ellis Center a one-stop shop, a holistic approach that's giving the services youth need, whether that be a hot meal, a place to be, freedom, recreational time, and, when they need them, medical services."

"Our goal is to have people feel celebrated"

The colocated medical clinic makes it more convenient for the center's patients to get the care they need. However, convenience is only one piece of the puzzle. Many LGBTQ youth report being stigmatized when seeking care in traditional primary care environments, encountering reactions of disgust or disdain. Medical staff may refuse to use LGBTQ patients' preferred names or pronouns, instead insisting on using legal names and gender assignations. According to Connolly, one in five trans people report having been denied medical care.

"Young people can walk into a waiting room and be met with confusion at the front desk and negative or funny looks in the waiting room itself," she says. "Even walking through the door takes an immense amount of courage, based on the experiences they've had in the past. Our goal is to have people feel celebrated. We want them to feel like we are throwing them a party when they come in, not just [using] the correct names and gender pronouns."

Brandi Smith came to the center as a client when she was 15 years old. Coming out as a trans woman of color in Detroit was not easy. When she did not find support at home, the Ruth Ellis Center helped her through her transition. Today, she serves as coordinator of the center's TransJustUs program, which offers retreats and support group services for trans women of color.

Brandi Smith at Ruth Ellis Center.

"Integrating medical and behavioral health into the Center's programming has been tremendous," she says. "For a lot of youth, myself included, it's hard to seek medical help when the people providing care won't even call you your preferred name. [There's] that constant battle to argue somebody down. [LGBTQ youth] need these services and need to be comfortable. It's one of the best things we did."

A freelance writer and editor, Estelle Slootmaker is happiest writing about social justice, wellness, and the arts. She is development news editor for Rapid Growth Media, communications manager for Our Kitchen Table, and chairs The Tree Amigos, City of Wyoming Tree Commission. Her finest accomplishment is her five amazing adult children. You can contact Estelle at Estelle.Slootmaker@gmail.com or www.constellations.biz.