4
Promising Interventions for Families and Communities
On the second day of the workshop, speakers and participants discussed how families and communities influence the health and well-being of LGBTQ youth and identified promising interventions in this area.
RESEARCH LANDSCAPE: OUTCOMES AND KNOWN INTERVENTIONS
LGBTQ youth are a dynamic and phenomenal group of people, said J. Garrett-Walker (University of Toronto); however, they live in a world that has many systems and structures in place that seek to oppress them. When compared to heterosexual peers, LGBTQ youth have higher rates of mood and anxiety disorders, higher risk of homelessness and food insecurity, and higher rates of suicidal ideation and victimization. These differences, said Garrett-Walker, are “solely due to the oppressive world in which they live.” Given that these disparities exist, she asked, what can be done about it? Family is critical in the development of a healthy psychosocial identity, she said, and family support allows LGBTQ youth to “live in their truth.” There are interventions that can improve a family’s ability to support and communicate with their child. For example, an online intervention has been developed to help families of trans children find the proper language to use, and it teaches them about key challenges facing their children (Sharek et al., 2021). Another online program offers resources including educational videos, videos of trans youth and their parents, and writing activities; focus groups examining this program reported positive feedback on the helpfulness of the program for participants (Matsuno and Israel, 2021). In
addition to families, communities can be enormously impactful in young people’s lives. A 2019 study found that young people who engaged with queer-focused, community-based organizations reported less substance use, and consistent participation in these organizations was associated with higher self-esteem (Fish et al., 2019). Neighborhoods, religious communities, and community-based organizations can support LGBTQ youth, or they can serve as a source of marginalization and oppression, said Garrett-Walker. To serve and support queer youth, we must seek to understand the nuanced experiences they have in their various communities, she said.
PROMISING INTERVENTIONS
In this session of the workshop, a panel of speakers presented information about family- and community-based interventions to improve the health and well-being of LGBTQ youth.
Family Interventions: Lead with Love and PATHS
There are decades of research on the powerful influence that parents have on adolescent health, said David Huebner (George Washington University School of Public Health). Regardless of sexual orientation or gender identity, the quality of parent-child attachment, parent monitoring, and parent-child communication impacts a child’s health and well-being. In addition, there is emerging research documenting the impact of parent behaviors in the LGBTQ context, including research on rejection and acceptance of a child’s sexual- and gender-minority (SGM) status, support for gender-affirming treatments, and communication about HIV and other illnesses. Despite this evidence base, said Huebner, interventions to address these influences are extremely limited. Support groups such as PFLAG1 have been offering support to parents for decades, but there is little empirical research that examines whether and how these interventions work. Clinical intervention models (e.g., trauma-focused cognitive behavioral therapy (CBT)) have been described by scholars but also lack empirical support. Huebner noted that researchers have recently begun to explore how interventions developed for the general population can be used in the LGBTQ population, including one study on sexual risk behaviors among gay and bisexual boys that reported positive results (Ocasio et al., 2021). There are a few interventions for parents of SGM youth that have some empirical evaluation, said Huebner; he identified four that he is aware of:
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1 In 2014, the organization officially changed its name from “Parents, Families, and Friends of Lesbians and Gays” to simply “PFLAG.”
- Attachment-based family therapy (Diamond et al., 2012);
- Lead with Love (Huebner et al., 2013);
- Parent Resource for Increasing Sexual Minority Support (PRISMS) (Goodman and Israel, 2020); and
- https://www.avawomen.com/avaworld/how-long-to-get-pregnant.
Before delving into the details of interventions, Huebner described the foundational premises of his work on interventions with parents of SGM youth. First, his work is based on the premise that parent behaviors are powerful predictors of the health of SGM youth and therefore intervening to change parent behavior is one approach to improving children’s health. Second, parents of SGM youth are fundamentally concerned about their children’s health and well-being even if they are expressing rejection. Huebner suggested that rejection is often a misguided expression of parental concern, and that even those parents who are not accepting of their child’s SGM status are often motivated to support their child’s health. The third foundational premise is that interventions need to reach parents where they are, both geographically and emotionally. Huebner’s research found that 85–90 percent of parents of SGM youth never attend any type of therapy or support group. Based on these premises, Huebner and his colleagues have developed two parent-focused interventions: Lead with Love and Parents and Adolescents Talking about Healthy Sexuality.
Lead with Love
Lead with Love is a film-based intervention designed to support parents, decrease parent rejection, and increase positive parenting behaviors (Huebner et al., 2013). The 35-minute film is documentary style; Huebner said this genre of education entertainment has been effectively used to change many types of behaviors. The film, which is available for free online,2 was accompanied by a multimedia promotion campaign upon its release. The film uses principles of motivational interviewing and stage-based theories of change. Huebner explained that the first goal in creating this intervention was to make parents feel “understood in their distress.” The second goal was to make parents aware that their distress is not because there is something inherently wrong with being gay, but because of a deep concern about their child’s well-being and a misunderstanding of what it means to be a sexual minority. The third goal was improving parents’ knowledge about sexual orientation (e.g., that it is not an illness and that it cannot be changed). Stories from parents and children are used to increase parents’ motivation to change their behavior; the stories discuss
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the negative impacts that parental rejection can have and the importance of parental love and understanding to a child’s well-being. The film also provides specific behavioral guidance to parents. The guidance encourages parents to “LEAD” with love:
- Let your affection show;
- Express your pain away from your child;
- Avoid rejecting behaviors; and
- Do good before you feel good.
The film was primarily evaluated through process data, said Huebner. In the first year, it reached 1,800 parents of LGB youth from 48 states. Of these parents, 21 percent had known about their child’s LGB status for less than a month, and 36 percent said having an LGB child was extremely or very hard for them. These data, said Huebner, indicate that the film is not just reaching the “worried well,” but is reaching parents who really need support. According to their evaluations, most parents found the film helpful, and there were significant increases in parents’ feeling of self-efficacy for parenting an LGB child. Fully 86 percent of parents who viewed the film had never accessed any other intervention or support. Huebner relayed a story about one family that accessed the film through a DVD order. Their home was in a tiny border town surrounded by cotton fields. Huebner noted that there are likely no PFLAG chapters or therapists equipped to provide LGBTQ-affirming care in this and other low-population areas. This highlights the need, said Huebner, for interventions that can reach families in every inhabited corner of the world.
Parents and Adolescents Talking about Healthy Sexuality
The second intervention developed by Huebner and his colleagues is called Parents and Adolescents Talking about Healthy Sexuality (PATHS) (Huebner et al., 2021). The ultimate goal of this intervention is to reduce HIV-related sexual risk behaviors among gay and bisexual adolescent boys. Huebner said the intervention seeks to accomplish this by targeting parent behaviors that are shown to be supportive of adolescent sexual health: communicating with their sons about HIV, instructing their sons on the mechanics of condom use, facilitating their sons’ access to condoms, and helping their sons get HIV tests. The intervention is based on the integrated behavior model and is aimed at increasing parents’ self-efficacy to support their children’s sexual health, improving attitudes, reducing barriers around parent support for adolescent sexual health, and changing parents’ expectations about the consequences of talking about sex. PATHS is delivered through an online application that includes videos of parents
and adolescent health experts, animated clips, and goal-setting activities. Huebner and his colleagues conducted a randomized, controlled trial to evaluate this intervention, with 61 ethnically diverse parent-child dyads, and found that the program significantly increased both parent and child reports of how much information parents shared about HIV, how much instruction they provided about condom use, and how much they facilitated their sons’ access to condoms. In addition, families in the intervention group reported that their children were more likely to get tested for HIV in the 3 months following the intervention.
In closing, Huebner identified several challenges and needs in this area. There is a need for intervention models that can reach people where they are, geographically and emotionally, and that are appropriate for diverse families (e.g., across differences in ethnicity, family composition, and religion). Huebner said that the needs of gender-diverse youth need to be addressed, though these young people may need interventions different from those designed for sexual minority youth. He noted that there are almost no interventions for parents of gender-diverse youth that have any empirical support, and he encouraged the development of complementary interventions to address the needs of LGB youth and gender-diverse youth. Huebner also stated that parent-focused interventions need to be designed not only to increase general parent acceptance, but also to help parents engage in the specific behaviors that are likely to have an impact on the health risks that SGM youth disproportionately face. In conclusion, Huebner suggested that future interventions need to be described thoroughly to enable dissemination and replication, and that efforts to accurately measure the efficacy of those interventions would benefit greatly from rigorous evaluation.
Community Intervention: Community Centers and CenterLink
LGBTQ community centers provide incredible prevention and intervention services to youths, said Deborah Levine (CenterLink). CenterLink supports, strengthens, and connects a network of over 270 LGBTQ centers, 83 percent of which have a youth program or exclusively serve youths. Levine began her presentation by describing in general terms what these centers do and who they serve. She noted that centers are highly responsive to youths; a survey showed that youth demand is the most important factor in deciding which services to offer, and many centers have formal or informal youth leadership programs. Providing general support and activities is a main function of these centers. For example, many have drop-in spaces with TVs, art supplies, snacks, and comfortable seating, and hold gatherings such as support groups, educational programs, movie nights, and proms. Even if a youth cannot attend the center often, said Levine, just the knowledge that it exists can be a support. Centers also provide social services, including
mental health counseling, family support, STD testing, healthcare, and access to computers, meals, clothing, laundry services, and showers; centers may also refer youths to other agencies to serve needs not met by the center. The staff at these centers also advocate for LGBTQ youth in the community, by providing professional development for teachers, counselors, and healthcare providers; providing consultation advocacy at the system level; and initiating and supporting GSAs—student-based support groups bringing LGBTQ+ and allied youth together to build community—in local schools. Levine noted that many centers have few staff members, and nearly one-quarter of CenterLink centers are entirely volunteer run. Since the beginning of the COVID-19 pandemic, many of these services and support mechanisms have been conducted virtually (see Box 4-1).
The services offered by LGBTQ centers are not particularly innovative, said Levine. What makes these centers work is “the village” of adults who are looking out for youths, helping to smooth the transition to adulthood, remedying the hurts that youths experience, and advocating to prevent future harm. Unfortunately, there is a lack of research to document the impact of this community work, she said. Levine argued that there is a critical need for researchers to engage with community centers, to compensate participants for their time, and to have clear plans for disseminating the results in the community. Positive results from such research could be used to encourage funders to support the growth of LGBTQ youth programs, Levine said.
Even with the lack of data, community-based LGBTQ youth support programs are being scaled up and replicated. People in communities—from hairdressers to woodworkers—have stepped up to develop youth programs. Organizations such as libraries, churches, and recreation departments can implement programs in their communities. The primary challenge to scaling up, said Levine, is funding. A secondary challenge is providing the appropriate training and education for those who want to do the work. People who are part of the LGBTQ community need training on working with young people, and people who work with youths need training on working with LGBTQ youth. Those already in the field need professional development to ensure that their work continues to have the intended impact. For example, centers are reporting an increase in gender-diverse youth, youth of color, and younger youth, so staff may require specialized training and resources to appropriately serve these populations. Levine stressed the importance of finding ways to serve youths who experience other intersecting inequities, for example, LGBTQ youth of color. Almost half of CenterLink’s programs serve primarily youth of color, and these centers are more likely than others to provide key social services such as educational programs, job placement, and transitional housing. As the community center model is scaled, she said, it is essential that communities of color have the resources and staff necessary to “be the village” for LGBTQ youth of color.
Community Intervention: Rainbow Pride Youth Alliance
Rainbow Pride Youth Alliance (RPYA) was formed in 2001 when “a group of LGBTQ Black, Indigenous, people of color (BIPOC) youth showed up to a gathering of mostly white, cisgender LGBT adults and said, ‘We need a safe space to be,’” said Reverend Benita Ramsey (Rainbow Pride Youth Alliance). RPYA is volunteer led and serves youths ages 12–26 in the Inland Empire area of California. Its mission is to “provide a safe, healthy, and enriching environment for LGBTQI youth to grow.” RPYA offers comprehensive services that promote the well-being and empowerment of
LGBTQ youth, using a social justice development framework that centers around youth perspectives and amplifies youth voices. Ramsey explained that youth voices guide the programming, pedagogy, and organizational structure of RPYA, and from the program’s inception youths have been equally positioned as governing board members.
RPYA offers weekly support groups using a proven model that positions 1 hour of educational time between 2 hours of social time, said Ramsey. Other services include art and wellness workshops, GSA support, and youth leadership development. RPYA also works to support youth engagement and leadership in schools and faith communities. The staff of RPYA reflects the diversity of the community, said Ramsey; they “live, work, play, and attend spiritual services” in the area, are familiar with neighborhood histories, and have established relationships with key “cultural brokers.”
Ramsey’s presentation also highlighted the Pride Youth Leadership and Resiliency Project, a school- and community-based program for LGBTQ youth that was adapted from the Fairfax Resiliency Prevention strategy. The program is aimed at preventing substance use and justice-system involvement by improving resiliency in three areas: healthy relationships, goal setting, and coping strategies. There are five main areas of activities in the program, noted Ramsey. First is a weekly resiliency group that builds social competencies and includes discussions on topics such as substance use, peer refusal skills, oppression, and spirituality. The second activity uses the creative and performing arts to strengthen protective factors. In this activity, youths create “classrooms” to depict a typical day for LGBTQ youth who face bullying, harassment, and the pressure to use substances. Parents, educators, service providers, and elected officials are invited to attend, and after each performance the youths facilitate community dialogue to discuss ideas for change. These performances serve both to recruit new participants and to provide participants the opportunity reframe their cognitive perceptions and develop shared norms, said Ramsey. The third activity is service learning, which helps to create school and community bonds and to build relationships with positive role models and other caring adults. Activity four is monthly adventures such as hiking and fishing. These adventures allow youths to gain experiences in positive risk taking and decision making, which can lead to increased self-reliance, coping skills, and the ability to manage risks in day-to-day life. Finally, said Ramsey, the program includes a youth-led digital network designed to educate parents and caregivers on LGBTQ history, with information on the school-to-prison pipeline, the war on drugs, and laws that protect LGBTQ youth.
Young people have great insights and ideas, said Ramsey, and they should be included as active partners in developing strategies to improve their own health and the social conditions of their lives. She emphasized
the value of creating opportunities for youths to lead, not to simply have a seat at the table. The active participation and leadership of young people can help ensure that culturally responsive, affirming, trauma-informed prevention and treatment services are available to all youth who need them. Brown also called attention to the importance of funders and programs creating opportunities for LGBTQ youth of color to be compensated for the time and energy they put into these programs. In short, she said, “let [youth] speak; their voices change hearts and minds.”
REFLECTIONS
Following the panelist presentations, planning committee member Jama Shelton (Hunter College) led a discussion session with panelists. Workshop audience members were also invited to submit questions for panelists via the virtual livestream. Shelton began by asking panelists to think about who is not at the table but could be an integral part of reducing inequities for LGBTQ young people. Levine responded that parents are an untapped resource. LGBTQ community centers were founded at a time when there was an assumption that most parents would not be involved in supporting LGBTQ children, she said, and this paradigm is shifting quickly. Parental involvement at centers should be encouraged, and trusted community allies (e.g., faith leaders) could be used to connect with parents who may be reluctant to work with centers directly. Ramsey added that LGBTQ people who are parents are sometimes overlooked; these individuals and their children bring a unique perspective to the table, and they can be compassionate partners when working with other parents. In addition, she said, foster parents and other caregivers need support and training, and are welcome at RPYA’s parent services. Huebner noted the need to better engage with faith partners across the spectrum. He said that it is possible to find common ground and to make progress even in churches that do not explicitly embrace the LGBTQ community. Ramsey concurred and said that they engage with faith leaders on issues like homelessness and food insecurity, and from there “we are able to navigate some of the stickier conversations around the needs of LGBT youth.” Ramsey reemphasized the importance of youth sharing their voices and elevating their stories to reach nontraditional partners.
A workshop participant followed up on Levine’s response to ask how centers engage with parents and families. Levine answered that one common strategy is to hold support meetings for youths and parents that are separate but simultaneous. She described one center that does not hold a formal group for the parents but serves coffee while the parents are waiting for their children—the parents are essentially attending a support group, but it has the feeling of an informal, organic gathering. In addition, centers often conduct trainings in the communities where parents are gathering, for
example, at Parent Teacher Association meetings and through faith-based organizations. Another common way that centers engage with parents, said Levine, is through advocacy for an individual student; for example, by helping a family navigate a gender transition in the school system. Huebner added that, in his experience, parents want to engage in “all of the spaces that their kids are spending time in,” from schools to swim teams to LGBTQ youth centers. He agreed that there has been a major shift away from the idea that parents are the “enemy” and he encouraged centers to find ways to include all parents, even those who lack the time or ability to volunteer.
Shelton asked speakers to comment on the role of “chosen family” in providing support for young people in the LGBTQ community. Ramsey replied that it is very common for young people who are not accepted at home to create a network of chosen family. This is one of the reasons, she said, that her organization offers adult-youth experiences to build relationships. Levine said that LGBTQ centers use explicit conversations about chosen family as a way to orient young people to the LGBTQ community and to encourage them to proactively build a supportive network. Even when a child’s family of origin is supportive, it can be helpful to have a chosen family within the community, she said. For youths who are unstably housed, some centers coordinate “host homes,” where supportive adults are assisted by the centers in offering space to young people.
Another workshop participant asked about the role of LGBTQ elders and intergenerational connections to help support LGBTQ youth. Levine responded that a number of centers have LGBTQ elders as volunteers, and described one center that mixes seniors with young people for job training. However, much of the work in this area is informal, and Levine said it would be useful to have a more formal understanding of how to develop and support intergenerational relationships. Huebner added that, when considering new programs like this, it is important to consider existing programs outside of the LGBTQ space that could be adapted for the community. “We don’t need to reinvent the wheel every time,” he said.
