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LGBTQ Youth of Color
In the key concepts and framing session, Allen Mallory emphasized the significant racial and ethnic diversity among LGBTQ youth. Russell Toomey noted that, despite progress in some areas, disparities between LGBTQ youth of color and cisgender, heterosexual youth continue to increase. LGBTQ youth are overrepresented in the child welfare and juvenile justice systems, and this overrepresentation is particularly acute for LGBTQ youth of color, said Naomi Goldberg. Despite this overrepresentation the experiences and perspectives of LGBTQ youth of color are often absent from research and policy development, said Mallory; in particular, the effects of the intersectional nature of systems, stigma, and discrimination on this population are poorly understood.
This chapter brings together insights from two panels aimed at highlighting these issues by focusing on outcomes and interventions for LGBTQ youth of color. In the first panel, LGBTQ youth of color discussed barriers and solutions to support well-being; this panel was followed by presentations on the state of research on, and services to support, the well-being of LGBTQ youth of color.
LIVED EXPERTISE
Planning committee member Nat Duran (Illinois Safe Schools Alliance) served as moderator of the Lived Expertise panel and guided the discussion through a series of questions as listed below. The panelists were Manal Vishnoi (Northbrook Pride Youth Program), A.J. Valdez (El Paso, Texas), Malcolm Lin (University of Kansas), and Zara Khan (Chicago, Illinois).
How Do You Define Health and Well-Being?
Vishnoi said that they consider health and well-being to be a combination of many components, including mental health, physical health, community health, and social support systems. Valdez defined health and well-being as being composed of one’s physical and mental state. Lin said that it is “the ability to live and be a prosperous, happy person.” Finally, Khan defined health as a person’s mental, physical, and emotional state of being, and said that well-being is when “someone is in a comfortable state of being.”
What Are Promising Solutions to Inequalities in Health and Well-Being That You Have Seen Work in Your Communities?
In August 2019, replied Valdez, there was a mass shooting in El Paso, Texas. Out of this tragedy came the El Paso United Family Resiliency Center, which offers free counseling to people of all ages, backgrounds, and creeds. Valdez emphasized the value of this center, suggesting similar centers should be opened in communities across the country. Vishnoi agreed with this idea and added that physical health services could also be offered at these centers, because many people cannot afford healthcare otherwise. Lin emphasized the need for access to healthcare, arguing that people should not need to drive for over 20 minutes to see a doctor. Lin said that each community may need more than one center so that people can be seen without long emergency room wait times. In addition to ensuring access, said Khan, it is critical to educate communities about mental, emotional, and physical health. Khan said that, as an Asian-American, she has observed harmful stigma in her community around mental health; educating people and providing healthcare resources would be very helpful. Specifically, she said, discussing “self-care” as a concept of everyday wellness, rather than as a luxury or self-indulgence, could help people see self-care as achievable for everyone. Valdez agreed, saying that self-care can be as simple as relaxing at home. Vishnoi proposed that topics such as self-care and mental health should be included in the curricula of health classes.
What Are the Barriers to These Types of Solutions?
One of the biggest barriers to the suggested solutions, said Lin, is that many people do not know how to help a person who is different from a “standard White person.” Lin said that some mental health professionals are unsure of how to approach a person with an unfamiliar issue, or someone who is a “kind of person” they haven’t encountered before; for example, there is an expectation that everyone has a loving, caring family and enough food to eat.
These barriers make it more difficult for people of color or people who are different to get help. Vishnoi added that many health systems are built to work against people of color and LGBTQ people of color, specifically. For example, internalized bias from providers can negatively impact the experiences of LGBTQ people of color within the health system. Kahn agreed, noting that some health issues, such as mental health, are not always visible. For people who are already marginalized, she said, “society doesn’t always listen.” Kahn emphasized the importance of believing people when they express how they are feeling. Vishnoi noted that, while many health organizations have attempted to address these issues by establishing a diversity board or hiring a diverse person, health systems require systemic change to better serve LGBTQ people of color.
Who Are the Influential People in Your Community and How Can We Support Them?
Parents and families have a considerable influence on young people, said Khan, and rejection of LGBTQ youth by their families can lead to negative consequences, including isolation and higher suicide rates. Khan suggested that healthcare providers or schools could provide resources and education to parents to help them better understand, support, and validate their LGBTQ children. When parents are not supportive, said Valdez, young people can receive support and validation in a supportive school environment. The first foundational step to changing the school culture, he said, is putting anti-discrimination policies in place to mitigate future discrimination and opposition to identity-affirming programs. Vishnoi said that schoolteachers and counselors can have a large influence on both students’ experiences in school as well as on their lives post-graduation. Allies in education could receive training to better prepare them to function as trusted adults for all types of students, Vishnoi suggested. Valdez added that teachers who take part in LGBTQ advocacy in schools need support from the administration and other higher-ups, particularly in communities where these activities can be controversial. Lin concurred that teachers and counselors are extremely important, and said that one of the best ways to support them would be to increase educators’ pay. Teachers are “the reason that we are who we are today.”
If You Had a Magic Wand, What System Would You Change and How?
Lin said that they would change the mental health system to give mental health professionals a broader mindset about how they can help people and how to simplify the process for patients. Valdez and Khan offered ideas for changes in the educational system. Valdez would redesign schools so
that teachers recognize and work with the various ways that students learn, while Khan would want students to learn about their rights, both inside and outside of school, and would make sex education curricula more inclusive (e.g., normalize asexuality). Vishnoi went a step further, saying that “all of those systems need to be torn down and built back up.” The systems were built to serve White, cisgender people, Vishnoi said, and they need to be rebuilt with young people, people of color, LGBTQ people, and other marginalized people in mind to effectively serve and support these communities.
What Are Common Misconceptions About Youth?
Many adults, said Vishnoi, have internalized the idea that youth are “stupid.” Vishnoi said that if adults took the time to listen to young people, they would realize that youth are smart, can understand complex ideas, and often know what they need. This attitude, Vishnoi said, prevents systems from serving youth properly. Valdez agreed, saying that adults often see youth as naïve or ignorant. He said that all people, regardless of age, should treat one another with respect and aim to respectfully discuss differences. Valdez stressed that respect should go both ways, and that while adults are sometimes not as respectful or attentive as they should be, teenagers can also lack respect and attentiveness. Another misconception, said Khan, is that youth are not capable or responsible. Khan drew attention to the magnitude of student and youth activism and noted that many political and social movements are predominantly youth led. Kahn suggested that youth need opportunities to learn the skills of advocacy and social change. Lin said that adults commonly think that their time and their responsibilities are more important than those of youths. Lin remarked that disregard for the value of youth time and youth priorities is a key reason why many young people do not want to work or return to school. Vishnoi agreed with Lin and said that “a lot of adults see youth of color as lazy, uncaring, and not having any ambition,” and that this is partly due to adults dismissing the priorities of youth. This view of youth of color, Lin said, is a harmful misconception and can be difficult for young people to overcome. Further, said Lin, this view can contribute to pay inequality and discrimination in hiring, which furthers existing disparities.
How Does Your Racial or Ethnic Identity Shape the Way You Experience Your Sexual Orientation and/or Gender Identity?
“I grew up in a very, very White town,” said Vishnoi. As a person who is half Indian and half White, a feeling of isolation resulted from not knowing many people with a South Asian identity. “Being alone in that way,” Vishnoi said, helped them to more quickly realize that they were nonbinary
and what that meant. Because Vishnoi already felt excluded from many things, feeling excluded from womanhood was not a new or unique feeling.
Valdez was a “stereotypical football player,” so coming out was a “big shock to everyone.” While coming out to his Mexican-American family was “rocky” at first, his family is now “completely supportive.” After coming out, Valdez’s father told him, “Since the day you were born, I was your first and last line of protection against anything, and now I’m even more so your first and last line of protection against anything or anyone.”
“I grew up very stereotypically Asian,” said Lin. When Lin came out, their parents did not believe they were nonbinary or pansexual. “They shoved everything about me as a person under a rug,” said Lin, which felt “very disheartening and painful.” Taiwan, where Lin’s family is from, was one of the first countries to support LGBTQ rights. This led Lin to believe that they would be safe coming out to their parents, but their parents responded in a very “old fashioned” way. Because of this, Lin is very self-protective and tries to “stay away from things [if] I know I’m going to get hurt.”
Khan’s parents are both from India, but they were not very socially conservative. When Khan came out, there were people who told them that it was “not possible to be Indian and also to be a member of the LGBTQ community.” Historically, Indian culture was open to LGBTQ people, said Khan, until Victorian era reforms in the 1860s began repressing “anyone who was not cis or straight.” Coming out as an LGBTQ individual who is Indian American has resulted in a “lot of push and pull between different identities,” Khan said.
How Do You Think COVID-19 Has Impacted LGBTQ Young People and the Community as a Whole?
Duran noted that there were concerns that the isolation during the COVID-19 pandemic would lead to negative consequences for LGBTQ youth. However, anecdotes suggest that some young people are feeling more empowered: Valdez’s GSA club1 has seen enormous growth, and his school district has received an unprecedented number of gender-support plan requests. Duran asked for panelists’ thoughts on the impact of COVID-19 on LGBTQ youth. Vishnoi said that the pandemic provided a lot of time to self-reflect and gave young people “the space to really explore their identities.” Valdez agreed, noting that the beginning of the pandemic had an emotional impact that led to him coming out. Khan added that the pandemic also encouraged people to connect in virtual communities, and
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1 The clubs were formerly known as Gay-Straight Alliances; now they are referred to either as Genders & Sexualities Alliances or simply GSAs.
that some people were able to interact, for the first time, with people who have similar identities. Valdez reported that, although his high school is fairly conservative, a large number of students have come out recently—he estimates that “maybe a fifth or fourth of the entire school is now out.” This shift is visible, with students adopting “a completely different style and … aesthetics.” While the isolation of COVID-19 was difficult, “we came back stronger,” Valdez said. The GSA at his school is part of a “little political revolution,” and aims not just to help LGBTQ-identified students, but to bring the entire student body together. In closing, Valdez urged young people to “use [your voice] and run with fire.”
RESEARCH LANDSCAPE
There are a number of patterns of inequality evident in the literature on LGBTQ youth of color, said Carlos Santos (University of California Los Angeles). LGBTQ youth of color are at greater risk of HIV infection (Balaji et al., 2013; Celentano et al., 2006), they are more likely to lack access to information about HIV/AIDS (Voisin et al., 2013; Mustanski et al., 2011), and they are less likely to know their HIV status or follow up with appropriate medical care compared to White, non-Latino, sexual-minority youth (Magnus et al., 2010). The mental health literature is mixed, said Santos, with some studies suggesting that LGBTQ youth of color experience greater mental health problems compared to Whites, others finding that they experience fewer mental health problems, and still others finding no difference (Toomey et al., 2017). Mono-racial samples have found evidence of poorer mental health among LGBTQ youth of color (Fields et al., 2015). There is also evidence of differences between LGBTQ youth of color and White youth in terms of substance use; for example, one study found more negative sexual health consequences of drinking among Black LGBTQ youth (Burns et al., 2015).
With this background, Santos turned to the limitations of the literature on the well-being of LGBTQ youth of color. He emphasized the importance of adopting an intersectionality framework for research on this population, and he outlined some of the critical aspects of such a framework. First, he said, researchers should avoid focusing on social identities alone. While identities are important, they are only one part of a complex story. It is essential to capture the oppressions that are associated with social identities (e.g., racism, heterosexism), and how these oppressive forces overlap to create unique conditions. As an illustration, Santos asked workshop participants to imagine reading Sojourner Truth’s “Ain’t I a Woman” without the context of the oppressive forces of racism or sexism. Further, he said, effective research will consider how oppressive forces and social identities are experienced both contextually and relationally, and how measurement
and design might best capture the contextual and relational nature of the experiences of LGBTQ youth of color. Santos emphasized that not all oppressions are the same. Anti-blackness and anti-indigeneity are foundational social, political, and economic forces in the history of the U.S., he said, and they need to be centered in studies of LGBTQ youth of color. Anti-blackness, racism, and colorism should be central to any study that purports to adopt an intersectionality framework, said Santos. Further, the role of state-sponsored status and legality are also critical to examine when studying the experiences of those with ties to other nation states.
One barrier to studying and capturing intersectional phenomena is a lack of intersectional measures in the field. One approach, he said, may be to adapt existing measures; for example, Lewis and colleagues (2017) adapted an existing racial identity scale to measure gender racial identity. Similarly, Sarno and colleagues (2021) have developed measures to capture perceived racism in the lesbian, gay, and bisexual (LGB) community and feelings of conflict in sexual- and gender-minority people of color’s allegiance to their ethnic-racial and sexual-minority identities. Using adapted measures, VanDaalen and Santos (2017) found that Asian-American participants perceived higher levels of racism in the LGB community than did Latinx participants. Santos encouraged researchers to consider intersectional issues across multiple systems and levels of systems. For example, LGBTQ youth experiences may be shaped by microsystems such as perceived racism or conflicts between multiple social identities, mesosystems such as lack of access to culturally sensitive health providers, and macro-systems such as state laws and policies. Santos also encouraged researchers to adopt frameworks that connect intersecting dimensions of resilience; for example, considering questions such as, “How does Black liberation tie to the neurodiversity movement for LGBTQ black youth who may live with disabilities?”
Finally, Santos encouraged researchers to work with LGBTQ communities using methods like the community-based participatory research framework. Santos suggested that issues can arise when research is performed in these communities without involvement of individuals from these communities in the planning, design, or implementation of a study. While representation does not solve all problems associated with researching historically minoritized and marginalized communities, he said, representation still matters. Beyond involving community members in research, researchers should consider how to channel resources toward community groups that are doing critical work, rather than funding people who are already in privileged positions.
EXPLORING RACISM AND SEXUAL IDENTITY DURING THE COVID-19 PANDEMIC
Karina Gattamorta (University of Miami) presented information on the impact of racism and family rejection on sexual- and gender-minority (SGM) stressors and mental health. At the start of the COVID-19 pandemic, said Gattamorta, SGM students were hypothesized to be a hyper-vulnerable population, due in part to the potential of returning to homes where they could face elevated stressors, such as family rejection and identity concealment. An online survey examined the relationship between these types of stressors and mental health among SGM college students during the COVID-19 pandemic. Gattamorta described how the data from the survey were used to examine two issues: first, changes in frequency of racism and SGM-related stress since the start of the pandemic and whether these factors led to psychological distress; second, relationships between racism, family rejection, identity concealment, and internalized homophobia. Gattamorta noted that the study was guided by both the intersectionality framework and the minority stress framework. The researchers utilized a number of existing tools to measure racism, SGM stressors, and psychological distress, and they adapted these tools to specifically examine changes during the pandemic.
The first study, said Gattamorta, aimed to answer three questions:
- Whether, since the start of the COVID-19 pandemic, increased frequency of racism and SGM stressors predicts current psychological distress;
- How, since the start of the pandemic, the relationship between increased SGM stressors and current psychological distress changes when adjusting for experiences of racism; and
- Whether, since the start of the pandemic, increased racism moderates the associations between increased SGM stressors and current psychological distress.
Young adulthood is a time of vulnerability for poor mental health, particularly for SGMs (Fish, 2020; Fish et al., 2019, 2020), and COVID-19 has had a disproportionate impact on communities of color (Czeisler et al., 2020; Liu and Modir, 2020; Moore et al., 2020). It was hypothesized, said Gattamorta, that students who hold both racial and SGM identities may have compounding experiences of vulnerability due to the COVID-19 pandemic. The data showed that the independent effects of increases in racism, family rejection, internalized homophobia, internalized transphobia, and identity concealment were all associated with greater psychological distress. When controlling for racism, the associations held but were somewhat attenuated. However, the moderating effects of increased racism on
the associations between each SGM stressor and psychological distress were not statistically significant.
The second study focused specifically on the two stressors of family rejection and racism. Of the approximately 200 students in the sample, 65 percent reported increased family rejection during the pandemic, and 67.5 percent experienced an increased in racism. The study sought to examine the impact of changes in the external stressors of family rejection and racism on the internal stressors of internalized homophobia and identity concealment. The data showed that all four of the measured stressors were significantly and positively related to each other, said Gattamorta. For example, experiencing both increased family rejection and increased racism was significantly associated with a greater likelihood of experiencing increased identity concealment compared to experiencing either racism or family rejection alone, or no stressors at all.
These studies and others make clear, said Gattamorta, that racism and SGM-related stressors have a unique impact on mental health. It is critical, she said, that universities and mental health stakeholders acknowledge and address these stressors, particularly in the context of the COVID-19 pandemic. Gattamorta offered three suggestions for how this could be realized: (1) increase access to affirming and culturally sensitive mental health services and providers, both on and off campus; (2) increase training and resources to ensure a public and mental health workforce that is well equipped to address needs related to racism and SGM stressors; and (3) increase engagement of SGM students of color in mental health services through affirming practices and allyship.
SYSTEMS OF SUPPORT
The individuals who are “pushed to the side” at other youth-focused organizations are the ones that the Ruth Ellis Center and Trans Sistas of Color Project focus on reaching, said Lilianna Reyes (Ruth Ellis Center). Specifically, these organizations reach out to Black and Brown youths who are homeless, may not be in school, and who often do not have access to other agencies or resources. The Ruth Ellis Center is Michigan’s largest lesbian, gay, bisexual, and transgender (LGBT) homeless youth services organization; it offers services including a drop-in center, hot meals, and a closet. In addition, this organization works with the Trans Sistas of Color Project to help trans individuals get their names and gender markers changed. The center is currently building the first ever LGBT long-term supportive housing shelter in Detroit, which will allow young people to stay as long as they need, said Reyes.
When the COVID-19 pandemic began, the Ruth Ellis Center had to adapt its procedures. While many organizations shifted their services online,
this approach was not feasible for the Center’s clients, many of whom did not have homes or access to electricity or Wi-Fi. The Center held meetings outdoors, started delivering food, and offered technology to those who needed it. Reyes noted that many Black and Brown community members gathered regardless of the COVID-19 restrictions, because “the thought of being isolated and not being around the people and family that you love was scarier than getting COVID.” The center did its best to practice harm reduction and to “meet folks where they were at.”
The Ruth Ellis Center is based on the idea that young people should have a voice in every aspect of the organization, and that a youth can and should one day become the executive director or board president. “We don’t just say that and throw it to the wind, we really believe it,” said Reyes. All of Reyes’ current staff are from the community, and started out as youths who were homeless, receiving services at the center, or part of the associated healthcare center. These youths may have difficulty getting other jobs because of criminal background checks, inaccurate names or gender markers, or a lack of a high school or college diploma. The Ruth Ellis Center helps people gain the skills and resources they need to be successful, and holds the belief that the best people to serve the community are people from the community itself. The Ruth Ellis Center takes a housing-first approach, but views housing as not just a physical space but also a frame of mind: “where you feel safe and where home is.” The center focuses on undoing racism and considers the intersection of identities in the community. Reyes said that “when you center the most marginalized, everyone benefits.”
Reyes noted that trans women of color are one of the most marginalized and vulnerable communities, and the Trans Sistas of Color Project was established to uplift this community. Trans Sistas of Color helps the community by providing emergency assistance for individuals, conducting policy work to facilitate gender changes, and supporting families when a trans woman is murdered. Many young trans women with unstable housing turn to sex work, said Reyes, noting the potential dangers. The Ruth Ellis Center and the Trans Sistas of Color Project work with these girls and women to “help them figure out what lifestyle they want to lead” and to support them along the way.
REFLECTIONS
Following the presentations, planning committee member Amorie Robinson (Ruth Ellis Center) led a question-and-answer session with the panelists. Workshop audience members were invited to submit questions for panelists via the virtual livestream. Robinson began with an observation that individuals who are gender nonconforming can sometimes get “lost in the data”—their experiences can be overlooked in research
and practice. These youths—such as those who are perceived to be gay, feminine-presenting boys and masculine-presenting girls—are likely to be targets of anti-LGBTQ attacks and are prone to mental health risk factors, she said. Robinson asked speakers to comment on ways to provide support, understanding, and protection for these youths. Gattamorta agreed with Robinson’s assessment, noting that researchers tend to “lump” together racial and ethnic minority or SGM populations, despite unique experiences. One issue, she said, is that small sample sizes lead to a lack of statistical power when trying to examine these groups. It can be difficult to access a sufficient number of participants from marginalized populations, Gattamorta said, and there is a need for more research in this area. Santos added that intersectionality-inspired research needs to focus on addressing the needs of those who are the most likely to experience the deleterious effects of being historically minoritized and marginalized. When these voices are centered, it can change the types of research questions, approaches, and measures that are used.
A workshop participant asked speakers to address the issue of balancing efforts to build resiliency among LGBTQ youth of color with efforts to hold institutions accountable for their roles in harming or failing to support LGBTQ youth of color. Reyes responded with the suggestion that these activities be pursued in tandem. She said that the Ruth Ellis Center originally focused only on individuals, and on building up resiliency so that young people could better navigate the obstacles and oppressions they faced. As the Center gained more capacity and experience, it began working on pushing back against systems themselves. Challenging racism and other oppressions on a systemic level, said Reyes, requires being comfortable with conflict and with the discomfort of others, and using one’s privilege to push for change. In addition, she noted, having the support of the board and other decision makers is critical for navigating difficult conversations and holding people accountable. For example, if a funder takes actions that are “not conducive to the liberation of Black and Brown people,” the organization may have to reject that source of funding, said Reyes.
Another workshop participant asked for ideas for how services and researchers that focus on youth of color can be more inclusive of LGBTQ youth, and how those that focus on LGBTQ populations can be more inclusive of youth of color. Gattamorta responded that it is essential for research and intervention design to be informed by the community, and for community members to be empowered to participate at all stages. She recalled that the panel of LGBTQ youth spoke about the importance of listening to young people and giving them space to have a voice in work that affects their own lives. Santos added that there are several benefits to using a community-based participatory research framework, and that it is important to go beyond paying lip services to participatory research and
to meaningfully engage with the community at every step of the research process.
Robinson next asked the panelists how to reach and engage with LGBTQ youth and their family members who do not understand or accept an LGBTQ child. This group, she said, likely includes many young Black and Brown people who need protection in their homes, schools, and communities. Reyes replied that “family of origin is sometimes where the biggest trauma happens,” and that it is not always possible or appropriate to have family unification as a goal. She emphasized the importance of not only considering ways to support and engage biological families, but also of looking at the role that chosen family can play. She explained that when we broaden our definition of family, we have more resources to draw upon in supporting LGBTQ youth. Santos added that one approach for engaging with people is to highlight how intersecting forms of oppression and privilege impact every individual. For example, as a queer Latino individual, Santos is subject to the forces of heterosexism and racism, but he also experiences privileges as a cisgender man. Having conversations about the intersections between various identities and related oppressive forces can help people better understand and be more mindful of their positions in society, and thus provide a framework for exploration of these issues.
The topic of outcomes and well-being for LGBTQ youth of color was also raised in another workshop session focused on existing research on inequalities, prevention, and intervention. In the question-and-answer session, planning committee member David Chae (Tulane University) asked speakers to comment on the role of racism within LGBTQ contexts, specifically sexual racism in gay communities and gay online spaces, as a potential cause of racial inequities in health and HIV. John Pachankis (Yale School of Public Health) responded that large nationwide surveys showed that perceived discrimination within the gay community is a more robust predictor of the mental health of young gay and bisexual men than traditional minority stressors such as stigma, bullying, and family rejection. Chae said that one concept that can be used to explain this is “invisibilization,” in which a person is invisible within his or her own community; Chae said this experience is largely driven by racism. José Bauermeister (University of Pennsylvania) added that racism in these spaces has an impact on physical health as well; the racialized sexualization in online spaces shapes the sexual network of these communities and impacts how HIV is spread. Bianca Wilson (University of California) noted that racism also has a major impact on how the LGBTQ community thinks about young people in state systems such as foster care. There is a tendency, said Wilson, for people to see the overrepresentation of LGBTQ youth in state systems and think, “We need to get those terrible parents of color to stop rejecting their youth.” However, the data show that most LGBTQ youth of color enter state systems
prior to identifying as LGBTQ. Increased state surveillance of Black and Brown communities filters children into the foster care system, explained Wilson. There is a racist element, she said, in the close scrutiny of Black and Brown families and there is a lack of attention to the structural racism that underlies the foster care system.
As a follow-up, Chae asked speakers to imagine what an intervention for reducing racial inequalities within LGBTQ youth contexts might look like. Bauermeister responded that he was not sure about a specific intervention, but that there is a need for greater investment in multilevel strategies. While there are various places where interventions can and do happen, he said, they tend to happen in siloes. Instead, we need multidisciplinary projects that coordinate and build distinct types of interventions in different kinds of spaces and that focus not just on young people but also on the people in their social ecology. Bauermeister acknowledged that this was a “big ask” and would require significant financial resources; he suggested that federal agencies such as the National Institutes of Health and the Centers for Disease Control and Prevention might contribute toward this type of initiative. He also stressed that the interventions themselves are most effective when they are flexible and adapted to the needs of unique communities. Wilson concurred and said that multilevel approaches can target structural determinants of health, rather than simply acknowledging their existence. As an example, Wilson described an intervention her colleagues developed to improve the health of HIV-positive Black gay and bisexual men, which provides legal assistance to challenge housing discrimination and discrimination in other contexts. Much of the intervention is still focused on the individual level, she said, but it also seeks to change individuals’ relationships to the structural-level issues that we tend to name but not directly target for change.
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