Ballroom Icons and the Power to Promote COVID-19 Vaccination Among Black and Brown LGBTQ+ Individuals

COVID-19 mortality is inequitably affecting communities of color in the United States. The rate of COVID-19 among Black and Latinx Americans is more than double that among Whites.^1–4 Black individuals account for 13.4% of the US population, yet they constitute 24% of COVID-19 deaths.^5(p19) Disproportionately represented as essential workers, Latinx individuals are 1.9 times more likely than Whites to contract COVID-19, 2.8 times more likely to be hospitalized, and 2.3 times more likely to die from COVID-19.^1,4 Also, research has shown that in Chicago, Illinois, Black and brown individuals have died of COVID-19 at higher rates than others.^6,7

Systemic racism has led to many individuals experiencing housing instability, job insecurity, and food deserts.^3,5,8,9 This systemic oppression increases the incidence of diabetes, hypertension, and other comorbidities, thereby worsening the impact of COVID-19.^5(p1),10 To support vaccination uptake among communities of color, we must address dissuasive barriers such as concerns about missing work to obtain the vaccine, inadequate information related to vaccine affordability, and historical mistrust of the health care system stemming from medical abuse of Black and brown bodies.^5,9,11

Examples of abuse abound, including forced sterilization of Puerto Rican women, removal and storage of Henrietta Lacks’s cervical cells, and the Tuskegee Syphilis Study.^10,12 More recently and relevant to COVID-19 vaccines, there have been lawsuits claiming that Johnson and Johnson did not properly disclose the link between its baby powder and ovarian cancer, instead continuing to market the product aggressively in Black and brown communities.¹³ This history of abuse and oppressive research contributes to many feeling unsafe in following public health advice.

RACE, SEXUAL ORIENTATION, AND GENDER IDENTITY

The intersection of race, gender, and sexuality within Black and brown LGBTQ+ (lesbian, gay, bisexual, transgender, queer or questioning, and others) communities compounds stigma, oppression, and health disparities.^9,14 Although these communities continue to experience blame, shame, and stigma correlated with infectious diseases such as HIV/AIDS (and other sexually transmitted infections), historical myths and conspiracies about HIV/AIDS being a “white gay male disease”¹⁵ have led to exclusion of Blacks from AIDS organizations, resources, and information. After decades of medical neglect and mistrust shaped by racism and homophobia, HIV/AIDS disparities persist among Black gay men.^5,16 These lived experiences may contribute to COVID-19 vaccine hesitancy among the Black and brown LGBTQ+ community.

Communities of color, who make up 42% of the LGBTQ+ population, are less likely to receive a COVID-19 vaccine than their White, cisgender, and heterosexual counterparts.¹⁷ In Chicago, vaccines are generally available, yet perceived lack of access and vaccine hesitancy have caused vaccination efforts to stall. Access is hindered by transportation challenges, limited clinic hours, lack of knowledge about where to access vaccines, and requirements for preregistration or appointments. Although access and hesitancy are distinct issues, initiatives addressing both are needed to increase vaccinations.¹⁷

In response to the needs of those with decreased access to vaccinations, the University of Illinois Chicago and the City of Chicago Department of Public Health have collaborated to increase vaccination rates. The COVID Rapid Response Team (CRRT), a collaboration between the University of Illinois Chicago’s Colleges of Nursing, Pharmacy, and Medicine and the department of public health, has been working since the earliest days of the pandemic to reach vulnerable individuals living and working in congregate settings (shelters for those experiencing homelessness, residential treatment centers, correctional institutions, and long-term care facilities).^18,19 Since March 2021, the team has engaged in vaccination efforts in these settings as well as in subsidized housing and social service agencies.

Using trauma-informed approaches,^20,21 CRRT has delivered the vaccine to more than 1500 people. Relying on approaches such as motivational interviewing,^22–24 CRRT aims to honor people’s experiences through trauma-informed care while providing vaccine education. In keeping with the mission of CRRT, the Black LGBTQ+ House Ball Community and CRRT are partnering to increase uptake of the COVID-19 vaccine.

VACCINATION IN CELEBRATION OF HOUSE BALL COMMUNITY

With COVID-19 restrictions lifting, the House Ball Community is resurfacing. House Balls celebrate Black LGBTQ+ culture and highlight the charisma, uniqueness, nerve, and talent of this community.²⁵ In addition, House Balls and shows such as Pose have shed light on the history of HIV/AIDS in the community.²⁶ Recently, Billy Porter (an Emmy Award winner for his work on Pose) has broken his silence about being HIV positive,²⁷ representing how one can successfully live with HIV. House Balls in Chicago draw more than 350 people who compete in 25 categories such as voguing, drag realness, and realness with a twist.

Participants are typically affiliated with houses, which are families of choice (rather than physical structures). All houses have names (e.g., House of Verocity, House of Gucci) and parents (e.g., Father Jahari Stamps). House parents provide a structure of support for Black and brown individuals who identify as LGBTQ+. As trusted mentors, they have historically protected their children by providing a safe haven, teaching survival techniques, and fostering creative expression. House parents have the power to lead by example and support healthful innovation. Many houses rely on community-based organizations such as CRRT to support House Balls as venues at which individuals can socialize while accessing health-related resources.²⁸

Chicago House Balls are usually held on the city’s south side, an area regularly served by CRRT. In celebration of creativity and in response to the needs of the Black and brown LGBTQ+ communities, CRRT connected with the city of Chicago and House Ball organizers to offer COVID-19 vaccines at a ball on May 16, 2021. Responses were mixed. CRRT vaccinated 13 individuals on the sidewalk outside of the venue and spoke to hundreds in line for the ball. Some were already vaccinated, but others shared their reasons for holding off, including seeing TikToks or online viral videos discouraging vaccination. Several believed that their COVID-19 experience was out of their hands. One person mentioned that “God has a plan,” and another stated that “I haven’t been social distancing this whole time and I’ve been fine.”

Misinformation about the role of boosters came up when someone said “Why would I get vaccinated now if I have to get revaccinated in six months anyway?” Another statement reflected a lack of understanding about the role of the vaccine in reducing severity: “I can still contract COVID-19 if I am vaccinated!” Trust also came up. One person was concerned about a lack of cultural concordance, stating that “I am going to trust someone that looks like me who says don’t do it before I trust you [saying that I should be vaccinated].” Others did not want the vaccine offered; for example, according to one individual, “I don’t trust Johnson and Johnson. Their powder sucks so I can’t even imagine what they would do to a vaccine.” Finally, the practicality of the approach was questioned when someone prioritized the opportunity to enter the ball over the vaccine by saying “I don’t want to lose my place in line to get vaccinated.” Two individuals who were excited to get vaccinated at the ball changed their minds after peers questioned the safety and legitimacy of vaccination.

Given the importance of houses and families, there is an opportunity to engage with House Ball Community leaders to overcome some of these barriers. After having been hesitant, House Ball legend (and coauthor of this article) Jahari Stamps chose to get vaccinated at the ball in May. His rationale was

to set an example for my sons and daughters and the community I call family. . . . I have to be the message that I bring to other people and my message is that this is bigger than our personal hang-ups. If we want to return to a level of normalcy, we need to get vaccinated not only to protect ourselves but also to protect the community I love. (Verbal Communication, May 31, 2021)

A CALL TO ACTION

Similar to successful outreach efforts related to HIV prevention, this anecdote suggests that a potentially effective approach is to engage house parents who are community leaders and legends. Diffusion of innovation theory has been used to promote behavioral change, and interventions that lean on this theory are effective because they consider early-, middle-, and late-stage adopters of change.²⁹ In keeping with this theory, House Ball icons such as Mario Balenciaga and other well-known house parents must be the face of safety to encourage others to follow suit. These community leaders are the individuals who can make the case for vaccination, and House Balls are the perfect venue for “one-and-done” vaccine delivery.

The lessons learned at the May 16 ball led to a change in strategy for a subsequent ball. Strategies implemented at the Paragon Ball on July 3, 2021, were in alignment with CRRT’s foundation of trauma-informed care and included a request for community leaders to be present and available for support during recruitment and vaccination. Respected leaders approached individuals entering the venue and encouraged them to get vaccinated. They offered to accompany individuals as they filled out the paperwork and received the vaccine. Vaccination took place in the lobby as people entered the ball, and thus they did not lose their place in line. Furthermore, a screen was erected to provide a semblance of privacy.²⁹ Palm cards stating the advantages of vaccination were distributed to ball attendees by community leaders and house parents. One side of the card had pictures of vaccinated icons, and the other side included a direct quotation acknowledging why the icon chose to become vaccinated.

A team of House Ball legends, house parents, public health nurses, and psychologists came up with ways to integrate vaccination into the ball experience.¹⁹ Although many individuals reported being vaccinated, approximately 5.5% of Paragon House Ball attendees were vaccinated at the ball, indicating that such outreach strategies may be an effective way to reach this population. An anecdotal indicator of success is that the MC of the ball took a break to get vaccinated after having been dissuaded by friends at the May event.

Although 5.5% might not seem like a large percentage, CRRT holds the philosophy, propounded by the Chicago Department of Public Health, that each person vaccinated is a life saved. In addition, each person vaccinated has the potential to persuade reluctant friends and family members, the late majority and laggards, to get vaccinated. Working with the Chicago Center for HIV Elimination, we will integrate these methods again at the Back to Basics Ball in October, where we plan to reach those who have yet to be vaccinated and hope to provide booster shots for those who qualify.³⁰

There are complex social and structural factors involved in COVID-19 vaccination (similar to HIV), including the intersection of race, sexual orientation, and gender identity, that keep in place historical barriers to accessing health promotion services; therefore, we can draw on the impact demonstrated by innovative HIV programs to better support the House Ball Community.³¹ To connect with underserved and difficult-to-reach populations, there is a clear need for innovative approaches. This is a first step.