Opinion Editorial

6. Nemoto T, Bödeker B, Iwamoto M, Sakata M. 10. Spinner CD, Boesecke C, Zink A, et al. HIV
Practices of receptive and insertive anal sex among
transgender women in relation to partner types,
sociocultural factors, and background variables.
AIDS Care. 2014;26(4):434-440. doi:10.1080
/09540121.2013.841832
7. Poteat T. Guidelines for the primary and
gender-affirming care of transgender and gender
nonbinary people, 2nd ed: transgender health and
HIV. http://transhealth.ucsf.edu/trans?page
=guidelines-hiv. Published 2016. Accessed June 25,
2018.
8. Garofalo R, Kuhns LM, Reisner SL, Mimiaga MJ.
Behavioral interventions to prevent HIV
transmission and acquisition for transgender
women: a critical review. J Acquir Immune Defic Syndr.
2016;72(suppl 3):S220-S225. doi:10.1097/QAI
.0000000000001084
9. James SE, Herman JL, Rankin S, Keisling M,
Mottet LA, Anafi M. National Center for
Transgender Equality: the report of the 2015 US
transgender survey. https://www.transequality.org
/sites/default/files/docs/USTS-Full-Report-FINAL
.PDF. Published 2016. Accessed June 25, 2018.
14. Garofalo R, Kuhns LM, Reisner SL, Biello K,
pre-exposure prophylaxis (PrEP): a review of
current knowledge of oral systemic HIV PrEP in
humans. Infection. 2016;44(2):151-158. doi:10.1007
/s15010-015-0850-2
11. Centers for Disease Control and Prevention.
Compendium of evidence-based interventions and
best practices for HIV prevention.
https://www.cdc.gov/hiv/research
/interventionresearch/compendium/index.html.
Published 2018. Accessed June 25, 2018.
12. Operario D, Gamarel KE, Iwamoto M, et al.
Couples-focused prevention program to reduce hiv
risk among transgender women and their primary
male partners: feasibility and promise of the
Couples HIV Intervention Program. AIDS Behav.
2017;21(8):2452-2463.
doi:10.1007/s10461-016-1462-2
13. Centers for Disease Control and Prevention.
Couples HIV Intervention Program (CHIP). https:
//www.cdc.gov/hiv/pdf/research
/interventionresearch/compendium/rr/cdc-hiv
-chip-good-rr.pdf. Published 2017. Accessed June
25, 2018.
Mimiaga MJ. Efficacy of an empowerment-based,
group-delivered HIV prevention intervention for
young transgender women: the Project LifeSkills
randomized clinical trial [published online August
13, 2018]. JAMA Pediatr. doi:10.1001/jamapediatrics
.2018.1799
15. Garofalo R, Johnson AK, Kuhns LM, Cotten C,
Joseph H, Margolis A. Life skills: evaluation of a
theory-driven behavioral HIV prevention
intervention for young transgender women.
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/s11524-011-9638-6
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doi:10.1007/s40429-014-0029-4

Structuring Research to Address Discrimination

as a Factor in Child and Adolescent Health
Nia Heard-Garris, MD, MSc; David R. Williams, PhD, MPH; Matthew Davis, MD, MAPP

Racial tensions and conversations about racial discrimina-
tion are squarely in the current collective consciousness of the
United States. Recurring police-involved shootings of people
of color, racially derogatory social media messages, and ra-
cially charged public pro-
Related article page 924
tests are accompanied by the
increasingly inflammatory
(rather than constructive) language of public figures and elected
officials. In this context, identifying and understanding how
discrimination affects the health of individuals from minor-
ity backgrounds (eg, race/ethnicity, sexual orientation, gen-
der identity, and religion) are particularly high priorities for re-
search and intervention. If we are to address major disparities
in health that fall along the fault lines of majority and minor-
ity communities, research must openly acknowledge and au-
thentically address discrimination, its causes, and its conse-
quences.
Discrimination, particularly racial discrimination, is known
to be associated with negative health outcomes.1 In a meta-
analysis by Paradies et al, 2 racism was associated with
poorer general physical and mental health (ie, depression,
anxiety, and psychological distress) in adults.3 Similar find-
ings were reported in 2 systematic reviews by Priest et al 4
and Sanders-Phillips et al5 focusing on children in which
racial discrimination was most commonly associated with
depression and anxiety in childhood and adolescence.
Discrimination is thought to play a critical role in health
disparities, especially for racial/ethnic minorities.6 However,
the underlying mechanisms that explain these pathways are
still being elucidated. One such mechanism is the influence of
discrimination on individual health behaviors. For example,
one study7 found that individuals exposed to frequent dis-
crimination were more likely to exercise vigorously but also
to demonstrate risky health behaviors, such as cigarette smok-
ing. The extant literature has largely focused on adults, and
much less is known about the role of discrimination on health
in childhood and adolescence.
In this issue of JAMA Pediatrics, Leventhal et al8 add to the
literature by examining the influence of discrimination on ado-
lescent health. The authors enrolled a diverse, prospective, lon-
gitudinal cohort of high school students in an urban center
whose voices are typically not well-represented within re-
search. Their conceptualization of societal, rather than indi-
vidual, discrimination was insightful, because individuals tend
to underreport individual discrimination and may more com-
fortably report discrimination experiences of others.9 Emerg-
ing research also suggests that individuals experience dis-
crimination vicariously through the experiences of others,
despite not being the initial target. These vicarious experi-
ences of discrimination may also influence health, and for chil-
dren and adolescents, this may be particularly salient.10 By fo-
cusing on societal discrimination, Leventhal et al8 may have
indirectly captured individual and vicarious experiences of dis-
crimination.
Importantly, Leventhal et al8 did not limit the scope of dis-
crimination to race/ethnicity only, but also included consid-
erations of immigrant status, sexual orientation, religion, and
disability status. With this broad conceptualization, Leven-

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 Editorial Opinion

Box. Addressing Discrimination as a Factor in Child and Adolescent Health

Conceptualization and Study Design • Assess the ethnic variation within minority populations (eg, com-
• Include a comprehensive conceptualization of discrimination, including paring Mexican Americans with Cuban Americans and Dominican
historical, direct, vicarious, group, societal, and structural discrimination Americans) and recent immigrants as compared with long-time US
(as measured by psychometrically validated tools6,10 when possible) in residents (eg, comparing black Caribbean immigrants with nonim-
pediatric mental and physical health–associated research studies. migrant black Americans).15
• Examine the role of intersectionality (defined as the intersection of • Routinely collect data on race and ethnicity, sexual orientation,
an individual’s many identities and/or dimensions12) on perceptions nativity, ability status, religion, and immigration status (if proper
of discrimination and subsequent health outcomes13 (eg, examin- protections are able to be ensured and maintained in collection
ing the discrimination experiences of someone who is Native and storage of such data).
American, transgender male who has a disability).
Interpretation and Outcomes
• Design longitudinal studies that examine the range of mechanisms
• Examine outcomes of distinct domains of discrimination (policies
(individual and structural) that adversely affect health and contrib-
[eg, federal, state, and local], systems [eg, schools, health care, and
ute to disparities for marginalized children and adolescents, and
justice], and media [eg, traditional media and social media]) to in-
track these outcomes into adulthood.
form population-level efforts to address health disparities.
• Use multigenerational models, in which discrimination in 1 genera-
• Partner with organizations that are prepared to translate findings
tion of adults influences subsequent generation(s) of children.10,14
into practice to disrupt discrimination-health pathways.
Sampling and Data Collection
• Sample racial/ethnic minorities across varying socioeconomic
strata, so that outcomes associated with minority status vs eco-
nomic status can be distinguished.

thal et al8 found that reported concern, worry, or stress about
increasing societal discrimination was associated with poor
self-reported mental and behavioral health outcomes in ado-
lescence. Respondents’ perception of increasing societal dis-
crimination was associated with higher frequency of sub-
stance use, including cigarettes and alcohol, as well as higher
odds of attention-deficit/hyperactivity disorder symptoms.
We believe that the study could have been improved with a
more neutral question about trends in societal discrimination
(ie, not to presume that trends were increasing). This study only
established associations between variables, not the direction of
causality. It is therefore impossible to establish if individuals’
mental health and health behaviors are shaping their perceptions
of societal discrimination or if causality flows in the other direc-
tion. However, studies of discrimination and mental health have
found that changes in discrimination are associated with changes
in mental health, and baseline mental health status is not asso-
ciated with subsequent reports of discrimination.1
Nonetheless, this study illuminates adolescents’ concerns
during a tumultuous political and social time in which individu-
als are experiencing discrimination directly through derogatory
and inflammatory language and actions; vicariously through tra-
ditional and social media outlets; and structurally through prac-
tices and policies with disparate effects on individuals and com-
munities. As the US population becomes a majority-minority
population with respect to race/ethnicity, tensions and conver-
sations are expected to continue and likely intensify. Youth are
the vanguard of diversity in the United States. Since 2013, most
infants born in the US have been nonwhite, and it is estimated
that by 2020 white youth younger than 18 years will become the
minority.11 Consequently, pediatric clinicians may increasingly
be faced with the adverse effects of exposure to discrimination
in the future, and they will need to be prepared to address the
health outcomes of discrimination effectively. To inform clini-
cal practice, research must critically and consistently examine
the role of discrimination in child and adolescent health. We pro-
pose a research framework to meet this goal (Box).
Adolescents are keen observers of the world around them—
just as the children they recently were, but with an even greater
attention to identity and self. Societal discrimination is a po-
tent signal of self and other, in and out, accepted and outcast.
Societal discrimination holds a mirror up to society’s percep-
tions of so-called others and models acceptable treatment of
those that are othered. In the current climates of media, poli-
tics, and social movements, adolescents may receive and per-
ceive messages that reinforce and perpetuate the falsehood of
hierarchy in the value of human lives. To truly take care of the
health of the whole person, researchers must engage in schol-
arship focused on the deleterious effects of discrimination and
thus inform clinical care and community outreach that can
favorably affect the future health of the population through
its youth.

ARTICLE INFORMATION
Author Affiliations: Division of Academic General
Pediatrics and Primary Care, Department of
Pediatrics, Ann & Robert H. Lurie Children's
Hospital of Chicago, Chicago, Illinois (Heard-Garris,
Davis); Department of Pediatrics, Northwestern
University Feinberg School of Medicine, Chicago,
Illinois (Heard-Garris, Davis); Mary Ann & J. Milburn
Smith Child Health Research, Outreach, and
Advocacy Center, Stanley Manne Children’s
Research Institute, Ann & Robert H. Lurie Children’s
Hospital of Chicago, Chicago, Illinois (Heard-Garris,
Davis); Department of Social and Behavioral
Sciences, Harvard University T.H. Chan School of
Public Health, Boston, Massachusetts (Williams).
Corresponding Author: Nia Heard-Garris, MD,
MSc, Division of Academic General Pediatrics and
Primary Care, Ann & Robert H. Lurie Children’s
Hospital of Chicago, 225 Chicago Ave, Chicago, IL,
60611 (nheardgarris@luriechildrens.org).
Published Online: August 20, 2018.
doi:10.1001/jamapediatrics.2018.2335
Correction: This article was corrected on October 1,
2018, to edit the association of the article by
Sanders-Phillips et al with citation number 4 and

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 Opinion Editorial

the article by Priest et al with citation number 5.
These have been corrected to citations 5 and 4,
respectively.
Conflict of Interest Disclosures: None reported.
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.1016/j.socscimed.2011.07.026

A Social Justice Framework for Lead Policy

Jessica Wolpaw Reyes, PhD

It is well known that exposure to lead in childhood has sub-
stantial and societally significant adverse effects on health, cog-
nition, and behavior. It is less clear how, given scarce re-
sources, society should best address the threats that lead poses.
In this issue of JAMA Pediatrics, Braun et al1 provide impor-
tant insight into the latter question.
Braun et al1 show that a comprehensive, home-based,
primary prevention intervention for lead exposure succeeded
in reducing dust lead loadings but had less effect on blood lead
or behavior, only reducing
blood lead concentration in
Related article page 934 some children and not signifi-
cantlyimprovingbehavior.The
study’s results were, however, more promising in the population
of black children, whose blood lead levels were reduced by ap-
proximately one-third. How do we place these results in context?
First, there is a clear consensus that any level of lead ex-
posure is harmful to children. The literature has established
substantial adverse neurobehavioral and health effects of child-
hood lead exposure, with essentially no lower bound.2-5 A null
result in this article regarding the effects of lead exposure on
behavior does not purport to challenge this consensus.
Second, there is little consensus on which sources of lead
are most important or on which lead-exposure reduction strat-
egies are the most productive or cost-effective.6 While past poli-
cies such as the removals of lead from gasoline and paint were
feasible to implement and promptly effective, current policy
has stagnated in the face of political and legal inaction as well
as daunting challenges: decades of gasoline lead deposition
near roadways, extensive lead water pipes, widespread dete-
riorating lead paint, and legacy lead from inequitable indus-
trial location.7,8 The positive result in this article regarding the
effectiveness of comprehensive primary prevention does not
purport to settle these questions.
While no single article could resolve the policy uncertain-
ties in the lead arena, this careful randomized controlled trial
(RCT) can help us find a way forward. It sharpens what we know
about home-centered primary prevention, showing that such in-
tervention can be effective and safe. This finding is indeed both
new and promising. So much lead has been used in our built en-
vironment in the past 2 centuries, and in so many ways, that it
is truly difficult to remove it safely.6 A 24% to 47% reduction in
dust lead loadings is substantial, even if the baseline levels were
relatively modest. With strikingly high benefits of reducing lead
exposure,9 all news on that front is welcome. At the same time,
the article’s modest results do suggest that home-centered pri-
mary prevention may not be the first-best policy tool.
Turning attention to blood lead level and behavior, the in-
tervention does not generally produce significant improve-
ments. Given the overwhelming evidence for lead’s adverse
effects, it is important that we consider how these non-
results are connected to the design and implementation of the
trial itself. While the RCT intended to target children at some-
what increased risk, such targeting is difficult and imperfect,

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