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Behavior Therapy 55 (2024) 1318–1334

[Link]/locate/bt

State of the Science: LGBTQ-Affirmative Psychotherapy

Julian Burger
John E. Pachankis
Yale School of Public Health, Yale University

nisms, successfully implementing and disseminating

Sexual and gender minority (SGM) individuals experience treatment protocols, determining which contexts and client
significantly higher levels of depression, anxiety, and characteristics warrant adaptations to current protocols,
behavioral comorbidities (i.e., substance use, suicide) com- and understanding how LGBTQ-affirmative psychotherapy
pared to heterosexual and cisgender individuals. LGBTQ- can interact with structural and systemic conditions to exert
affirmative psychotherapy aims to ameliorate the adverse the strongest possible impact on SGM mental health.
psychosocial processes, ultimately caused by stigma, that
underlie this disparity. Over the past two decades, the men-
Keywords: sexual and gender minorities; LGBTQ-affirmative psy-
tal health field has introduced professional guidelines and
chotherapy; cognitive-behavioral therapy; treatment efficacy;
treatment protocols for LGBTQ-affirmative psychother- treatment mechanisms; implementation; dissemination
apy, and established their efficacy across distinct SGM
populations, delivery modalities, and settings. This state
of the science review outlines the history, current evidence, CONSISTENT EPIDEMIOLOGIC evidence shows that sex-
and future directions of LGBTQ-affirmative psychother- ual and gender minority (SGM) people represent
apy. It provides an historical account of clinically relevant one of the highest-risk populations for mental
research for SGM populations and outlines the factors that health problems, including major depression, anx-
moved the field from pathologizing perspectives to affirma- iety disorders, and behavioral comorbidities (e.g.,
tive approaches. It then discusses the current evidence for hazardous substance use; suicidal ideation and
LGBTQ-affirmative psychotherapy, as well as studies iden- attempt; sexual health risk; Beyrer et al., 2012;
tifying treatment moderators, including race/ethnicity and Fergusson et al., 1999, 2005; Hatzenbuehler
stigma exposure, as well as potential treatment mecha- et al., 2008; Hatzenbuehler & Pachankis, 2016:
nisms, including hypervigilance, shame, negative self- Lefevor et al., 2019: Marshal et al., 2008;
schemas, unassertiveness, and emotion dysregulation. Pachankis, Harkness, Maciejewski, et al., 2022).
SGM individuals can only benefit from LGBTQ- According to minority stress theory (Brooks,
affirmative psychotherapy if protocols are widely available 1981: Hendricks & Testa, 2012: Meyer, 2003),
and used by therapists. To this end, the article presents cur- the most plausible source of these disparities lies
rent findings on implementation and dissemination, such as in LGBTQ individuals’ experiences of unique
therapist training, and different treatment delivery modal- stressors related to their stigmatized identities
ities. Finally, the article outlines an agenda for future (e.g., peer bullying, family nonacceptance) and
research to advance the field of LGBTQ-affirmative associated stress reactions (e.g., hypervigilance,
psychotherapy, including identifying treatment mecha- shame, self-concealment), all of which are predic-
tive of adverse mental health outcomes. This the-
ory (Hatzenbuehler, 2009; Meyer, 2003) and its
supporting research (e.g., Hollinsaid et al., 2023;
Preparation of this article was supported by the David R. Kessler,
MD, ’55 Fund for LGBTQ Mental Health Research at Yale. John
Pachankis, Hatzenbuehler, et al., 2023) has laid
E. Pachankis receives royalties from Oxford University Press for the groundwork for the development of evidence-
books related to LGBTQ-affirmative mental health treatments. based LGBTQ-affirmative psychotherapies.
Address correspondence to Julian Burger, Ph.D., 60 College St., Although LGBTQ-affirmative psychotherapies
New Haven, CT 06520. e-mail: [Link]@[Link]. have a long history starting with the early LGBTQ
0005-7894/Ó 2024 Association for Behavioral and Cognitive Therapies. rights movement, an emerging body of rigorous
Published by Elsevier Ltd. All rights are reserved, including those for text research has arisen in recent years, incorporating
and data mining, AI training, and similar technologies.
 s t a t e o f t h e s c i e n c e : l g b t q - a f fi r m a t i v e p s y c h o t h e r a p y 1319
community-based feedback into clinical trials, to these assumed pathologies (Bieber et al., 1962;
now show the efficacy of these approaches. Given Green, 1972) and means of their eradication
that minority stress theory primarily specifies cog- (Barlow & Agras, 1973). These efforts to change
nitive, affective, and behavioral treatment targets sexual orientation and gender identity and expres-
(Pachankis, 2015), these more recent evidence- sion included, for example, aversion therapy using
based approaches have tended to be cognitive- unpleasant stimuli such as electric shocks to recon-
behavioral in nature. This state of the science dition “undesirable” aspects of sexuality and
review (Comer, 2024) outlines the history and gender-based experience (for a review, see Comer
development of LGBTQ-affirmative psychother- et al., 2023). These theories and practices colluded
apy and recent evidence underlying its efficacy, with the stigmatizing structural conditions of the
and outlines several future directions needed to time to condemn untold numbers of SGM individ-
ensure that efficacious, affirmative treatments con- uals to lives of projected sickness, solitude, and
tinue to reach SGM people in greatest need of criminalization (Pachankis, 2018).
mental health support. The early LGBTQ rights movement ushered in a
move away from pathologizing discourse toward
A Brief History of LGBTQ-Affirmative more affirming stances within the mental health
Psychotherapy profession toward SGM individuals. Indeed,
For much of the mental health field’s history, prac- research during this time, conducted mainly with
titioners conceptualized and treated homosexual- community samples in North America, reported
ity and nonconforming gender identities and overall similarities in the psychological character-
expressions as pathological experiences in need istics of sexual minority and heterosexual individ-
of eradication (Drescher, 2015; Silverstein, uals (e.g., Hooker, 1957), and same-sex and
2009). Until 1973, the Diagnostic and Statistical heterosexual relationships (Peplau, 1982). This
Manual of Mental Disorders (DSM; American research finding no difference, or even positive
Psychiatric Association, 2013) listed homosexual- adaptations (Thompson et al., 1971) between sex-
ity as a “sexual deviation,” subjecting untold num- ual minority and heterosexual individuals helped
bers of gay men and lesbian women to treatment justify that no mental health intervention was
of this “condition” via so-called “conversion ther- needed to modify SGM experiences or identities.
apies.” The seventh printing of the DSM-II, pub- Around the same time, the LGBTQ rights move-
lished in 1974, introduced “sexual orientation ment had formed grassroots community supports,
disturbances,” which regarded homosexuality as including identity-affirming mental health sup-
a problem worthy of treatment if the individual ports located in LGBTQ community spaces, fol-
showed distress stemming from their same-sex lowing a model of community-based
attraction and a desire to change it. In the DSM- empowerment (Martos et al., 2017; Silverstein,
III, published in 1980, this label was changed to 2009).
“ego dystonic homosexuality,” and the DSM-III- Although the research showing similarities
R, published in 1987, was the first to exclude between sexual minority and heterosexual individ-
any variant of homosexuality that would justify uals and between same-sex and heterosexual rela-
treatment. Similarly, transgender experiences were tionships reduced the pathologizing discourse of
included in the DSM-III in 1980 in the form of earlier research, by relying on nonrepresentative
“gender identity disorders.” Only with the publi- community sampling, this research also obscured
cation of the DSM-5 in 2013 did this focus on the possibility of distinct mental health experiences
transgender experiences as pathology shift to the by sexual or gender identity resulting from societal
experience of gender dysphoria. The gender dys- mistreatment and other environmental threats. In
phoria diagnosis remains controversial; on the fact, during the beginning of the 21st century, the
one hand, a diagnosis ensures access to health care, first population-representative studies to assess
on the other hand, it perpetuates a pathological sexual orientation clearly showed that sexual
notion of gender variance (American minority adults (Cochran & Mays, 2000a,
Psychological Association, 2015). Across this his- 2000b) and youth (Garofalo et al., 1999) were at
tory, both psychoanalytic (e.g., Bieber et al., significantly greater risk of poor mental health out-
1962; Socarides, 1977) and behavior therapy comes such as suicide attempts compared to their
(e.g., Herman et al., 1974; MacCulloch & heterosexual counterparts. During this time,
Feldman, 1967) approaches promoted pathologiz- increased governmental attention to, and funding
ing views of nonnormative gender-based behavior for, HIV/AIDS research, primarily among gay
and attractions through studying the etiology of and bisexual men, further heightened the focus
1320 burger & pachankis
on disproportionate health burdens borne by sex- extensions (Hatzenbuehler, 2009; Meyer, 2003)
ual minority compared to heterosexual individu- have identified such processes as potentially
als. Not only did these studies identify a higher promising treatment targets for LGBTQ-
burden of HIV/AIDS on the sexual minority male affirmative psychotherapy, and they continue to
population, but they also established co- inform the search for treatment targets today
occurring disproportionate risks of depression, (Pachankis, Soulliard, Morris, et al., 2023).
anxiety, and substance use problems (D’Augelli, Because these theories specify cognitive (e.g.,
1989; McKirnan & Peterson, 1988; Meyer, negative self-schemas), affective (e.g., shame),
1995). The HIV/AIDS epidemic also introduced and behavioral (e.g., unassertiveness) mechanisms
the first clinical trials of affirmative behavioral underlying the association between SGM individu-
approaches for sexual minorities, primarily in the als’ exposure to identity-related stress and adverse
form of stress management interventions for mental health, treatments informed by them have
HIV-positive gay and bisexual men (Antoni tended to be cognitive and behavioral in nature.
et al., 2006). Although these interventions did at Cognitive-behavioral therapies (CBT) also lend
times recognize and address the specific stress ema- themselves to being tested in randomized con-
nating from HIV infection and being a sexual trolled trials, given their potential for manualiza-
minority, their focus tended to be on stress man- tion and associated means of establishing internal
agement more generally. validity (e.g., fidelity checks). CBT-based treat-
Since that time and continuing to today, minor- ments have therefore formed the bulk of the
ity stress theory (Brooks, 1981; Hendricks & evidence base for LGBTQ-affirmative
Testa, 2012; Meyer, 2003) has called substantial psychotherapies (e.g., Craig et al., 2021;
attention to the distinct forms of identity-related Pachankis et al., 2022). Because these psychother-
stress that can stem from possessing an SGM iden- apies not only work to reduce suffering but also
tity. Consequently, significant psychotherapy offer an identity-affirming alternative to so-called
research since that time has focused on ways to “conversion therapies” and because they are con-
specifically adapt treatments to address this stress sistent with professional practice guidelines for
to enhance identity-related coping. This develop- providing affirming care to SGM populations
ment is notable in that few evidence-based inter- (Guidelines for Psychological Practice with Trans-
vention approaches up to that time were gender and Gender Nonconforming People,
specifically focused on addressing the concerns of American Psychological Association, 2015; Guide-
stigmatized populations, or really any distinct pop- lines for Psychological Practice with Sexual Minor-
ulation outside of diagnostically distinct groups. ity Persons, American Psychological Association,
Whether such population-distinct interventions 2021; McLachlan et al., 2019), the mental health
are indeed warranted remains an open question, field has tended to agree that these identity-
answered as much by empirical evidence as by eth- focused treatments are appropriate and warranted
ical and professional considerations (Pachankis, for SGM individuals.
2018). As a framework for organizing the stress
associated with holding a stigmatized sexual Empirical Evidence for LGBTQ-Affirmative
(Brooks, 1981; Meyer, 2003) or gender Psychotherapy
(Hendricks & Testa, 2012; Sevelius, 2013) minor- In addition to its theoretical fit to minority stress
ity status, minority stress theory has also served as theory and its amenability to clinical trials as
a useful model for developing interventions to help noted above, CBT is well suited as an affirmative
facilitate identity-focused stress coping. According approach to SGM people’s disproportionate bur-
to minority stress theory, early and ongoing expo- den of adverse mental health for several concep-
sure to identity-based victimization, peer bullying tual reasons (Balsam et al., 2006; Martell et al.,
and rejection, and family nonacceptance undermi- 2004; Pachankis, 2014). First, CBT locates sources
nes SGM individuals’ mental health across the of distress in social structures rather than personal
lifespan (Bränström et al., 2022). Specifically, deficiencies, aligning with an appropriately affir-
SGM individuals who are exposed to these social mative stance when delivering psychotherapy with
threats can develop coping adaptations (e.g., nega- SGM individuals. Second, CBT focuses on acquir-
tive self-schemas, shame, hypervigilance, ing cognitive flexibility to update internalized, neg-
unassertiveness) that, if employed as chronic, ative ideologies such as those emanating from
inflexible responses over time can generate poor early and ongoing exposure to stigma and minor-
mental health (Hollinsaid et al., 2023; Maiolatesi ity stress. Third, CBT aims to enhance adaptive
et al., 2023; Pachankis, Hatzenbuehler, et al., behavioral coping skills, and focuses on self-
2023). Minority stress theory and its clinical empowerment to implement these skills in daily
 s t a t e o f t h e s c i e n c e : l g b t q - a f fi r m a t i v e p s y c h o t h e r a p y 1321
life, thereby promoting self-efficacy to cope with CBT approaches can be effective. Indeed, case
stressful situations that individuals with stigma- studies of LGBTQ-adapted evidence-based treat-
tized identities face. These conceptual merits fur- ments remain relevant today as they lay the
ther position CBT as a suitable approach for groundwork for future systematic study of other
addressing identity-related stress experiences, theoretically grounded psychotherapeutic
especially given the increasing attention paid by approaches applied to SGM clients (e.g., Medley,
the mental health field to the ways in which struc- 2021; Staples, 2023).
tural, systemic forces jeopardize the well-being of As observational research increasingly validated
the stigmatized (Hatzenbuehler & Pachankis, the tenets of minority stress theory
2021). (Hatzenbuehler, 2009; Hendricks & Testa, 2012;
The earliest empirical evidence for the efficacy Meyer, 2003), and identified the mechanisms
of LGBTQ-affirmative psychotherapy stemmed through which minority stress compromised men-
from case studies illustrating the ways in which tal health (Bränström et al., in press; Hollinsaid
general existing CBT protocols could be adapted et al., 2023; Maiolatesi et al., 2023; Pachankis,
to the specific needs of sexual minority clients. Hatzenbuehler, et al., 2023), the mental health
For instance, these case formulations illustrated field took advantage of this blueprint to design
the utility of applying CBT techniques to address and test evidence-based treatments that could
identity-specific topics such as identity conceal- address these mechanisms (e.g., Pachankis,
ment (Glassgold, 2009; Safren & Rogers, 2001), 2014). To systematically ensure that targeting
hate-crime related stress (Kaysen et al., 2005), these theoretically and empirically validated mech-
and internalized stigma (Martell et al., 2004; anisms could appropriately respond to the charac-
Walsh & Hope, 2010). These case studies played teristic ways in which SGM people might cope
an essential role in the development of LGBTQ- with stress, Pachankis (2014) and colleagues
affirmative psychotherapies because they illus- (e.g., Jackson et al., 2022; Scheer et al., 2023) con-
trated how CBT principles and techniques could sulted with several dozen clinical experts as well as
be effectively mapped onto case formulations that SGM community members experiencing mental
included concerns specific to SGM individuals. For health challenges to identify the cognitive, affec-
example, Glassgold (2009) provided an example tive, and behavioral mechanisms through which
of the benefit of addressing a client’s concealment minority stress manifests in SGM individuals’ lives
behaviors and disclosure fears while addressing his and translated those consultations into principles
anxiety and panic symptoms within a CBT concep- and techniques, rooted in cognitive-behavioral
tualization. Similarly, Walsh and Hope (2010) approaches, that could inform treatments intended
reported that their client’s social anxiety scores to address those minority stress mechanisms
decreased most when shifting from a standard (Pachankis, Soulliard, Morris, et al., 2023).
CBT protocol to a case formulation that addressed These principles and techniques can theoreti-
their client’s struggles around his sexual orienta- cally be overlaid onto any existing evidence-
tion. Methodologically, of course, case studies based treatment, perhaps especially those rooted
pose several limitations to evaluating treatment in learning theory and cognitive-affective science,
efficacy. First, because case studies generally use to guide those treatments toward an LGBTQ-
pre-post designs without control conditions, treat- affirmative stance. The principles include, for
ment effects cannot be separated from natural example, normalizing depression and anxiety as
recovery. Second, the findings of case studies responses to minority stress, validating the painful
may depend on the specific context of the case impact of early and ongoing minority stress, sys-
(e.g., therapist or client variables), thereby obscur- tematically empowering SGM individuals to cope
ing the generalizability of treatment gains under with the psychosocial consequences of minority
different circumstances. Third, while these case stress, building relationships that support SGM
studies showcase the integration of LGBTQ- individuals’ authentic self-expression, drawing
relevant content to the practice of CBT, they did upon unique strengths of the LGBTQ community
not necessarily derive their LGBTQ-specific guid- and SGM individuals, and validating intersectional
ance from systematic empirical study of the appli- identities as sources of stress and resilience (Coyne
cation of specific approaches for addressing SGM et al., 2020; Pachankis, Harkness, Jackson, et al.,
individuals’ distinct presenting concerns. In sum- 2022a, 2022b; Pachankis, Soulliard, Morris,
mary, case studies laid an important groundwork et al., 2023). Accompanying CBT-based tech-
for demonstrating how LGBTQ-affirmative case niques that translate these principles into thera-
formulations could be used for SGM clients and peutic action include, for example, fostering
showed initial evidence that LGBTQ-informed insight into the ways in which minority stress
1322 burger & pachankis
experiences can shape one’s cognitive, affective, LGBTQ-affirmative CBT against stronger control
and behavioral experiences; approaches for build- conditions, such as LGBTQ-affirmative commu-
ing cognitive flexibility away from rigid, internal- nity counseling, using randomized controlled tri-
ized negative ideologies about SGM individuals; als. The one completed study to have done so
and behavioral experiments for building self- found that LGBTQ-affirmative CBT results in at
affirmation, especially in the face of ongoing least equal treatment success compared to current
stigma and minority stress (Pachankis, 2015). standards of LGBTQ-affirmative counseling as
These principles and techniques of LGBTQ- typically delivered in community settings, and
affirmative CBT provide a concrete way to trans- may be especially beneficial for treating comorbid
late more general long-standing guidelines for anxiety, depression, substance use, and HIV-
LGBTQ-affirmative mental health practice into transmission-risk behavior among young gay and
concrete therapeutic approaches, as explicitly rec- bisexual men (Pachankis et al., 2015a;
ommended by professional guidelines for mental Pachankis, Harkness, Maciejewski, et al., 2022).
health practice with SGM individuals (American Although comparative efficacy trials of LGBTQ-
Psychological Association, 2015; American affirmative CBT have only been conducted with
Psychological Association, APA Task Force on gay and bisexual men to date, research is under-
Psychological Practice with Sexual Minority way that compares LGBTQ-affirmative CBT to
Persons, 2021). existing treatments for gender-diverse sexual
In perhaps the first systematic attempt to adapt minority women for outcomes including haz-
an existing evidence-based treatment to be ardous alcohol use and comorbid depression, anx-
LGBTQ affirmative, these principles and tech- iety, and trauma-/stress-related disorders
niques were integrated throughout an existing (Pachankis et al., 2024).
transdiagnostic CBT protocol (Barlow et al., One additional benefit of increasingly larger tri-
2017), resulting in a nine-module therapist manual als of LGBTQ-affirmative CBT is that they bring
that could be tested in clinical trials. The initial greater statistical power to investigate research
efficacy of LGBTQ-affirmative CBT was estab- questions beyond treatment efficacy, such as iden-
lished in waitlist controlled trials, finding greater tifying moderating conditions and mediating pro-
improvements across outcomes, including depres- cesses of LGBTQ-affirmative psychotherapies. In
sion, anxiety, and substance use among young terms of treatment moderation in the above-
adult gay and bisexual men (Pachankis et al., mentioned comparative efficacy trial, the study
2015a) and gender-diverse sexual minority therapists nominated 20 possible moderators of
women, 43% of whom identified as transgender LGBTQ-affirmative CBT efficacy (e.g., client
or gender nonbinary (Pachankis, McConocha, demographic variables, pretreatment comorbidi-
et al., 2020), compared to a waitlist control. Sim- ties, clinical facilitators, minority stressors). From
ilar effects have been obtained in waitlist con- this analysis, only race/ethnicity emerged as a sig-
trolled trials for LGBTQ-affirmative CBT when nificant moderator, with Black and Latino gay
delivered to SGM youth in group settings within and bisexual men benefitting more from treatment
community organizations in Canada (Craig et al., compared to White gay and bisexual men in terms
2021; Craig & Austin, 2016), in pre-post trials of the pre-registered outcome (e.g., comorbid
when delivering the treatment to transgender and depression, anxiety, substance use problems, and
gender nonbinary individuals in Eastern Europe HIV-transmission-risk behavior; Keefe et al.,
(Lelutiu-Weinberger et al., 2024), and using 2023). Additional research has specifically exam-
game-like formats to sexual minority youth in ined stigma exposure across levels, including struc-
New Zealand (Lucassen et al., 2015). As another tural (Hatzenbuehler & Pachankis, 2021),
notable example of an evidence-based mental interpersonal (Pachankis, Williams, et al., 2020),
health treatment for SGM individuals, and internalized (Millar et al., 2016), as modera-
attachment-based family therapy, when adapted tors of LGBTQ-affirmative CBT efficacy. Overall,
to the concerns of nonaccepting parents and their this research paints a preliminary picture whereby
SGM adolescents, exerts improvements on SGM treatment efficacy depends on whether LGBTQ-
youth depression, suicidality, and attachment- affirmative CBT is adapted to address stigma-
related outcomes in open trials in the U.S. and specific concerns or not, and the level of stigma
Israel (Diamond et al., 2012, 2022). to which an individual is exposed (e.g., structural
An important step in establishing treatment effi- vs. internalized; Hatzenbuehler & Pachankis,
cacy involves comparing novel approaches against 2021). These studies have found that LGBTQ-
current treatment standards and practices. A affirmative CBT yields greater efficacy for individ-
newer wave of efficacy studies has thus examined uals living in areas with higher structural stigma
 s t a t e o f t h e s c i e n c e : l g b t q - a f fi r m a t i v e p s y c h o t h e r a p y 1323
(Pachankis, Soulliard, Layland, et al., 2023) and periods to assess mediation (e.g., Pachankis
for individuals with higher levels of internalized et al., 2020). Similarly, several additional studies
stigma measured implicitly and explicitly (Millar have examined candidate mechanisms in interven-
et al., 2016). Indeed, two highly similar trials of tion studies for SGM individuals beyond the con-
LGBTQ-affirmative CBT delivered asyn- text of LGBTQ-affirmative CBT, which might
chronously online found different effects, with a inform future studies of treatment effect media-
trial in the U.S. finding very small effects tion. For instance, online single-session interven-
(Pachankis, Soulliard, Layland, et al., 2023), and tions designed to reduce internalized stigma are,
a trial in China, a context with higher structural in fact, effective in reducing internalized stigma
stigma, finding much stronger effects (Yi et al., and increasing identity pride (Shen et al., 2023).
2024). SGM individuals’ experiences with inter- Further, other brief interventions, such as online
personal forms of stigma, including victimization, expressive writing and self-affirmation exercises
parental nonacceptance, and peer bullying, have for sexual minority young adults in high-stigma
not yet been found to serve as moderators of locales, have been shown to yield reductions in
LGBTQ-affirmative CBT, although they have been perceived stress en route to improving mental
shown to moderate the efficacy of specific compo- health (Chaudoir et al., 2023). Engaging with
nents of this treatment (Pachankis, Williams, et al., identity-affirming educational material via an
2020). online web application has also been shown to
To maximize treatment effects, the mental improve SGM individuals’ beliefs in their coping
health field needs to know more precisely how abilities as well as their actual coping skills
LGBTQ-affirmative CBT works. Research on (Bauermeister et al., 2022). Moving forward, test-
treatment mechanisms is crucial because it directs ing for whom treatment works best and the mech-
attention to processes that are particularly impor- anisms through which treatment effects are
tant to address in treatment and that can shape obtained will be important for further developing
future treatment development. To date, the search and tailoring LGBTQ-affirmative CBT and other
for treatment mechanisms has been guided by the- psychotherapies to specific clients and presenting
ory, namely minority stress theory and its exten- concerns. At the same time, given that none of
sions. As noted above, minority stress theory the above research has identified candidate mecha-
emphasizes the mechanistic role of chronic rejec- nisms that serve as statistical mediators of efficacy
tion expectations, identity concealment, and inter- of LGBTQ-affirmative psychotherapies, future
nalized stigma (Meyer, 2003), as well as emotion research might benefit from extending existing the-
regulation deficits, social isolation, and negative ory and observational research to identify such
self-schemas (Hatzenbuehler, 2009) that link mediators.
stigma exposure to adverse mental health condi-
tions among SGM individuals. In recent years, Dissemination and Implementation
population-based longitudinal cohort studies have With substantial efficacy evidence now estab-
confirmed the role of these mechanisms lished, LGBTQ-affirmative CBT lends itself to
(Bränström et al., in press; Hollinsaid et al., wide dissemination, further possible given its
2023; Pachankis, Hatzenbuehler, et al., 2023). potential for manualization (Pachankis,
Applying this theory and observational research Harkness, Jackson, et al., 2022a) and the relative
to the search for candidate mechanisms of ease of training providers in modularized psy-
LGBTQ-affirmative CBT, an analysis of data from chotherapies (Moras, 1993). In fact, the efficacy
254 young gay and bisexual men enrolled in a of training providers in LGBTQ-affirmative psy-
study of LGBTQ-affirmative CBT found that chotherapy has been examined in randomized con-
although none of the candidate mechanisms were trolled trials, finding that such training reduces
found to serve as statistical mediators of improve- providers’ implicit and explicit bias, especially if
ments following LGBTQ-affirmative CBT, ongoing supervision is provided, and that
improvements in emotion regulation difficulties improved LGBTQ competencies persist beyond
and assertiveness were the most strongly sup- one year (Lelutiu-Weinberger et al., 2022;
ported candidate mechanisms given their prospec- Pachankis et al., 2022). These improvements exist
tive associations with treatment outcome (Burger following both online trainings, as well as in-
et al., 2024). This finding is largely consistent with person trainings, and extend to training providers
the effects of earlier waitlist trials that also found working in locales with high structural stigma
comparatively stronger impact on emotion regula- (Lelutiu-Weinberger et al., 2022). Provider train-
tion difficulties following treatment, even though ing in LGBTQ-affirmative CBT, specifically, is
they did have sufficient sample sizes or follow-up well-supported: Therapists are motivated to
1324 burger & pachankis
partake in them (Fish et al., 2022), and directors of LGBTQ-affirmative CBT implementation given
frontline LGBTQ community mental health set- the fact that these centers respond to the mental
tings widely support providing the staff time and health needs of SGM individuals in local commu-
administrative support necessary to integrate this nities in the U.S. and worldwide, providing care
training into their settings (Pachankis et al., 2021). to many tens of thousands of LGBTQ individuals
Dissemination of LGBTQ-affirmative psy- each year, and that these centers tend to be recep-
chotherapies can also be facilitated by means of tive to staff training in evidence-based practice as a
efficient treatment modalities. For instance, group means to meet this need (Pachankis et al., 2021).
adaptations of LGBTQ-affirmative psychotherapy Indeed, in a survey of 60 directors of LGBTQ com-
are effective in decreasing minority stress, anxiety, munity centers in the U.S., 100% endorsed their
and depression symptoms (e.g., Goldbach et al., support for providing administrative supports for
2021), and have additional benefits such as their mental health staff to be trained in
reduced loneliness for Black and Latino sexual LGBTQ-affirmative CBT. Future research is now
minority individuals (Jackson et al., 2022). Group needed to determine the most effective ways in
delivery has also been tested in the context of which to go about this implementation, taking into
LGBTQ-affirmative adaptations of dialectical account the distinct local features of each LGBTQ
behavior therapy (DBT; Skerven et al., 2019), community center, their leadership and staff char-
and showed promise for decreasing emotion dys- acteristics, and distinct barriers and facilitators
regulation and depression symptoms in a study within each center that might predict sustained
of six sexual minority veterans (Cohen et al., LGBTQ-affirmative CBT uptake. Other national
2021). LGBTQ-affirmative treatments can also healthcare systems, such as the Veterans Health
be delivered via asynchronous online platforms, Administration, lend themselves to implementa-
with potential for larger reach compared to treat- tion sites of LGBTQ-affirmative mental health
ments delivered in person. Such online approaches care. Indeed, systematic research has taken place
are acceptable and feasible (Pachankis, Soulliard, to identify barriers and facilitators of a more gen-
Layland, et al., 2023), although evidence for their eral LGBTQ health education program within the
impact on mental health outcomes has been Veterans Health Administration (Wilson et al.,
mixed, with some studies showing null or small 2023). The barriers (e.g., anti-LGBTQ stigma)
effects (Pachankis, Soulliard, Layland, et al., and facilitators (e.g., leadership support) identified
2023; Shen et al., 2023), and others showing through that research might also inform future
robust effects across outcomes when compared implementation of LGBTQ-affirmative mental
to a control condition (Yi et al., 2024). LGBTQ- health care in this and similar nationwide settings.
affirmative online treatments seem to be most effi- Indeed, group-based LGBTQ-affirmative mental
cacious for SGM individuals exposed to high levels health programs have been successfully imple-
of stigma, perhaps because of the particularly mented in general community centers not specifi-
strong need for such treatments in such contexts cally focused on LGBTQ community, with low
(Pachankis, Soulliard, Layland, et al., 2023; Yi attrition, and high levels of engagement and
et al., 2024). acceptability of participants (Craig et al., 2021).
Implementation refers to the integration of a As discussed below, other future settings for imple-
treatment innovation, like LGBTQ-affirmative mentation include those located in high-need, low-
CBT, within existing structures and systems of resource locales globally, which introduce distinct
care. Successful implementation involves consider- specific implementation challenges and opportuni-
ations of the barriers and facilitators of uptake of ties for future research to identify.
the treatment in real-world practice settings,
including effective ways to train and supervise pro- Advancing the Science of LGBTQ-Affirmative
viders, the treatment’s acceptability to providers Psychotherapy: An Agenda for Future Research
and clients, and identified strategies for embedding This final section outlines an agenda for future
the treatment within existing care structures to research in the field of LGBTQ-affirmative psy-
ensure its sustainability (Sholomskas et al., chotherapy. Table 1 summarizes these research
2005). Although still in its infancy, the study of questions and their relevance for advancing the
implementation of LGBTQ-affirmative psy- field.
chotherapy has focused on identifying settings in
which to embed LGBTQ-affirmative CBT and identifying treatment mechanisms of
the facilitators and barriers of implementation lgbtq-affirmative psychotherapy
therein. For instance, this early work has identified As noted above, no candidate mechanisms have
LGBTQ community centers as optimal settings for been identified as statistical mediators of the
 s t a t e o f t h e s c i e n c e : l g b t q - a f fi r m a t i v e p s y c h o t h e r a p y 1325
Table 1
Future Research Questions for Advancing LGBTQ-Affirmative Psychotherapy
Research question Relevance
Identifying treatment mechanisms of LGBTQ-affirmative psychotherapy
What mechanisms underlie treatment effects? Maximizing treatment effects by focusing on mechanisms and
informing the development of future intervention approaches.
Do treatment mechanisms differ for different sub-populations? Understanding why treatment may be more or less effective for
specific sub-populations.
If treatment mechanisms differ for different sub-populations, Establishing a balance between having numerous distinct
should LGBTQ-affirmative psychotherapy protocols be treatment protocols and maximizing treatment effects for sub-
adapted for those sub-populations? populations.

Building the evidence base beyond cognitive-behavioral therapy approaches

Are other therapy approaches such as emotion-focused Expanding LGBTQ-affirmative psychotherapy to other
therapy (EFT) and interpersonal psychotherapy (IPT) therapeutic orientations beyond CBT and maximizing reach.
suitable for LGBTQ-affirmative adaptations?
What approaches are used by skilled clinicians in the Identifying effective treatment mechanisms and techniques
community that promote LGBTQ affirmation? that can extend the evidence base of LGBTQ-affirmative
psychotherapy beyond CBT.
How can LGBTQ-affirmative psychotherapy be combined with Advancing an intersectional approach to LGBTQ-affirmative
approaches focusing on stressful aspects of other psychotherapy, improving treatment outcomes for individuals
minoritized identities, such as racial minority identities? with multiple marginalized identities.

Expanding identity-affirmative psychotherapy research to other populations

Is LGBTQ-affirmative psychotherapy effective for different sub- Identifying sub-populations for whom current protocols are
populations (e.g., individuals with different cultural especially effective, and, conversely, for whom current
backgrounds; those who experience racism, those holding protocols are not yielding maximum treatment benefits.
intersectional identities and experiences, those who are
asexual)?
If LGBTQ-affirmative psychotherapy is not effective for various Identifying aspects of LGBTQ-affirmative psychotherapy that
sub-populations, what specific experiences of those sub- warrant adaptation to maximize treatment benefits for a given
populations should treatment adaptations focus on? sub-population.

Collecting effectiveness outcomes in real-world settings

How effective is LGBTQ-affirmative psychotherapy in real- Determining if effects found in randomized controlled trials hold
world settings? under real-world conditions.
What training modalities are most cost-effective for Determining the most cost-effective approach to implementing
disseminating LGBTQ-affirmative therapy (e.g., online and sustaining LGBTQ-affirmative psychotherapy.
courses, training, supervision)?
What adaptations do therapists naturally make to LGBTQ- Identifying areas of treatment adaptations that should be
affirmative psychotherapy protocols to respond to contextual formalized in future iterations of LGBTQ-affirmative
factors such as limited resources? psychotherapy to respond to contextual factors such as limited
resources.
What barriers and facilitators exist to implementing LGBTQ- Maximizing dissemination by addressing the specific barriers
affirmative psychotherapy in care settings? and capitalizing on facilitators for implementation.

Identifying presenting concerns for which identity-affirming psychotherapies are indicated

Under which conditions are identity-focused treatments, such Identifying the client characteristics that indicate whether
as LGBTQ-affirmative CBT, warranted? LGBTQ-affirmative protocols are recommended over more
general protocols.
Which type of LGBTQ-affirmative therapy is indicated for a Identifying client characteristics that indicate a specific type of
given client? LGBTQ-affirmative protocol (e.g., CBT, EFT, IPT).

Integrating LGBTQ-affirmative psychotherapy within structural interventions

Can delivering LGBTQ-affirmative psychotherapy within Understanding the bidirectional associations among structural
settings marked by structural stigma enhance the structural conditions, LGBTQ-affirmative psychotherapy, and SGM
climate of those settings, or conversely, does structural mental health.
stigma of those settings undermine the efficacy of LGBTQ-
affirmative psychotherapy?
To what extent do downstream interventions like Understanding LGBTQ-affirmative psychotherapy more
psychotherapy affect upstream improvements in structural broadly as part of a movement to promote SGM rights and
conditions? structural change.
1326 burger & pachankis
efficacy of LGBTQ-affirmative psychotherapies. tions will be crucial to further develop and tailor
This is at least partly a function of the relative lack LGBTQ-affirmative psychotherapy to specific cli-
of suitable existing data opportunities, with most ents and the psychosocial processes that might be
studies of LGBTQ-affirmative psychotherapy uti- particularly likely to affect them. The finding that
lizing small sample sizes, few follow-up periods, LGBTQ-affirmative CBT yields more efficacy for
and insufficient comparison conditions for inform- Black and Latino clients, for example, suggests
ing treatment mechanisms. However, identifying that specific experiences likely to be faced by those
the mechanisms through which LGBTQ- populations might be related to treatment effects
affirmative psychotherapy works holds promise (Keefe et al., 2023). Sexual minority people of
for maximizing treatment efficacy and informing color might be particularly likely to experience
the development of future intervention approaches minority stress or to possess particular capacity
and consequently represents a research priority. to respond to such stress by virtue of their racial
Although not tested as formal mediators of socialization experiences, thereby directing the
LGBTQ-affirmative psychotherapy, psychological search for targeted treatment mechanisms toward
experiences such as hope (Craig et al., 2021), emo- those experiences. In addition to client demo-
tion regulation difficulties, and unassertiveness graphics, other research has shown that various
(Burger et al., 2024) have been shown to be forms of stigma across levels serve as moderators
impacted by LGBTQ-affirmative psychotherapies. of treatment efficacy for SGM populations
Because these constructs are also consistent with (Hatzenbuehler & Pachankis, 2016). At the same
minority stress theory (Meyer, 2003) and its exten- time, the search for treatment personalization
sions (Hatzenbuehler, 2009), they might serve as needs to balance improved treatment outcomes
promising candidate mechanisms to be investi- with feasibility, given that multiple adaptations
gated as such in suitable future trials. At the same of a protocol can introduce implementation chal-
time, rigorous observational research has identi- lenges (Burger, 2023).
fied the relevance of constructs such as shame
(Pachankis, Hatzenbuehler, et al., 2023), hypervig- building the evidence base beyond
ilance (Hollinsaid et al., 2023), negative self- cognitive-behavioral therapy
schemas (Bränström et al., in press), adverse child- approaches
hood events, and inflammation (Bränström et al., CBT lends itself well to implementing the princi-
2024) as mediators of the association between sex- ples of LGBTQ-affirmative psychotherapy for the
ual orientation and mental health outcomes such empirical, conceptual, and professional reasons
as depression, as well as of the association between reviewed above, but CBT is obviously not the only
minority stress exposure and poor mental health therapeutic orientation with potential for affirm-
among sexual minority individuals. Although ing SGM experiences in psychotherapy. As the
these mechanisms have not been investigated as field of SGM mental health refines its theories
mediators of treatment efficacy, their established and evidence for the mechanisms underlying the
mechanistic role in the mental health of sexual substantial mental health disparities affecting
minority individuals supports the possibility that SGM people, it has potential to identify treatment
they might also play a key role in treatment effects. targets that are well-suited to other existing treat-
Future research guided by valid constructs, sound ment approaches outside of a CBT framework.
measurement, and relevant theory can aid in future For instance, existing evidence-based treatment
focal searches for mechanisms of treatment effi- approaches such as emotion-focused therapy
cacy. Indeed, new theories (e.g., social safety the- (Greenberg, 2004; Johnson, 2019) and related
ory; Diamond & Alley, 2022), additional approaches (e.g., accelerated experiential dynamic
constructs (e.g., shame; Pachankis et al., 2023), psychotherapy; Fosha & Yeung, 2006) lend them-
and data opportunities (e.g., trials of single- selves to addressing emotional experiences particu-
session interventions across diverse geographies; larly likely to be experienced by SGM individuals.
Shen et al., 2023) can facilitate this forward In fact, research and theory (Cardona et al., 2022;
movement. Pachankis, Hatzenbuehler, et al., 2023) have
Future research into treatment mechanisms of recently shown that traumatic identity invalidation
LGBTQ-affirmative psychotherapies can also be and its emotional sequelae (e.g., chronic shame)
informed by research on treatment moderators to play prominent roles in SGM individuals’ mental
advance precision medicine. For instance, identify- health. Emotion-focused therapies, which natu-
ing the client presentations for which LGBTQ- rally focus on the experiences and attachment-
affirmative psychotherapies work best and how based precipitants of discrete emotions, are like-
treatment effects are obtained for these presenta- wise suited to addressing emotional experiences
 s t a t e o f t h e s c i e n c e : l g b t q - a f fi r m a t i v e p s y c h o t h e r a p y 1327
such as shame that SGM individuals dispropor- expanding identity-affirmative
tionately experience as a result of early and ongo- psychotherapy research to other
ing attachment-based challenges (Pachankis et al., populations
2022; Rosario, 2023). Indeed, case studies of To date, the largest efficacy trials of LGBTQ-
LGBTQ-affirmative adaptations of emotion- affirmative psychotherapy have been conducted
focused therapies lay important groundwork for on LGBTQ-affirmative CBT with young gay and
how such adaptations might be more systemati- bisexual men (Pachankis et al., 2015b;
cally studied across SGM client populations into Pachankis, Harkness, Maciejewski, et al., 2022).
the future (Medley, 2021). At the same time, several studies find that
Similarly, interpersonal psychotherapy (IPT) LGBTQ-affirmative CBT is effective for gender-
lends itself to LGBTQ-affirmative adaptation diverse sexual minority women (Pachankis,
given its focus on identifying relational challenges, McConocha, et al., 2020), transgender and nonbi-
including role transitions and disputes, and build- nary individuals (Austin & Craig, 2019; Lelutiu-
ing healthy relational repertoires. Indeed, one of Weinberger et al., 2024; Pachankis, McConocha,
the core principles of LGBTQ-affirmative psy- et al., 2020), SGM youth (Austin et al., 2018;
chotherapy identified from community stakeholder Pachankis, Soulliard, Layland, et al., 2023), and
consultations involves building healthy close rela- SGM individuals in culturally distinct contexts
tionships in which SGM individuals can express outside of the U.S. (Diamond et al., 2022;
themselves authentically (Pachankis, Soulliard, Lucassen et al., 2015; Yi et al., 2024). Although
Morris, et al., 2023). Because SGM individuals minority stress principles are not restricted to a
often report relational difficulties within and out- specific form of identity, and therefore mecha-
side the LGBTQ community, greater social isola- nisms should be broadly applicable across the
tion (Garcia et al., 2020), and experiences of SGM spectrum and contexts outside of the U.S.,
loneliness (McDanal et al., 2023), LGBTQ- future research needs to examine the generalizabil-
affirmative adaptations of IPT could lend them- ity and boundary conditions of treatment efficacy
selves to being particularly effective psychotherapy across subpopulations, including asexual, intersex,
approaches for this population. Likewise, because trans-masculine individuals, those holding identi-
IPT is well-suited to addressing interpersonal chal- ties affected by intersectional sources of stress
lenges resulting from the social roles that one and resilience (e.g., SGM people of color), and
occupies, is assumed to occupy, or transitions to those living in cultural contexts outside of the U.S.
or from, SGM-focused case conceptualizations This research might perhaps find that LGBTQ-
involving social roles could likely benefit from affirmative CBT works similarly well for all popu-
the principles and techniques provided by IPT for lations or alternately that specific adaptations are
addressing such challenges more generally. required to increase acceptability and resonance
Ideally, the evidence base for LGBTQ- with distinct aspects of experience for any given
affirmative adaptations to these treatments would population subgroup. For instance, when adapting
proceed with the same careful community consul- LGBTQ-affirmative CBT to the cultural context of
tation, including with both providers and SGM China, specific adaptations were necessary to
therapy recipients, that characterized LGBTQ- reflect more collectivistic cultural norms, including
affirmative adaptations to CBT from the start normative pressures to conceal one’s sexual iden-
(e.g., Pachankis, 2015; Pan et al., 2021; Scheer tity and enter a heterosexual marriage and down-
et al., 2023). Psychotherapy process research, playing the centrality of personal assertiveness
including review of exemplar sessions by skilled (Pan et al., 2021). As another example, community
therapists in the community, can help identify consultation with sexual minority women and
potential mechanisms of LGBTQ-affirmative their therapists highlighted the relevance of com-
adaptations to these treatments and theoretically bining minority stress conceptualizations with a
compatible techniques for addressing them. Such feminist framework for addressing gender-based
research has particular promise because it identi- stressors specifically (Scheer et al., 2023). Further,
fies effective markers of change as they occur in for sexual minority men of color, group-based
the naturalistic treatment settings in which such adaptations have been shown to be particularly
treatments would ideally be disseminated more relevant for mitigating loneliness and the lack of
widely. Of course, the results of this naturalistic accurate mirroring that can emerge at the intersec-
process research can also be distilled into proto- tions of minoritized racial/ethnic identities and
colled approaches lending themselves to clinical stigmatized sexual identities (Jackson et al.,
trials research and therefore tests of their efficacy. 2022). Such research is consistent with an
1328 burger & pachankis
emerging body of work that similarly addresses affirmative psychotherapies, such studies could,
racial identities and associated stressors and for example, determine the impact of therapist
strengths using an evidence-based CBT framework training in LGBTQ-affirmative CBT on not only
specifically for people of color (Metzger et al., therapist outcomes (e.g., treatment fidelity) but
2021). The degree of compatibility, overlap, or also client outcomes (e.g., depression) as well as
potential synergy between treatment approaches hypothesized mediating processes on therapist out-
that address racial minority stress and SGM stress comes (e.g., therapist self-efficacy for delivering
represents an important direction for study as the LGBTQ-affirmative CBT) and client outcomes
mental health field increasingly attends to (e.g., internalized stigma). Implementation-
identity-centered treatments for stigmatized popu- effectiveness research in real-world settings can
lations. Finally, much of the empirical literature on also identify what adaptations therapists naturally
LGBTQ-affirmative psychotherapy focuses on sex- make to the treatment to respond to factors such as
ual minority individuals, and to a lesser extent on specific needs of a given client or contextual factors
gender minority individuals (Expósito-Campos such as limited resources, and whether such adap-
et al., 2023). Although the principles of LGBTQ- tations can and should be formalized in future dis-
affirmative CBT as originally developed with and semination of the treatment. This research can also
applied to sexual minority individuals have been identify solutions to delivering evidence-based care
suggested to apply in a very similar way to the in contexts of limited treatment resources. For
specific needs of transgender and nonbinary indi- instance, in such settings, perhaps more resource-
viduals in theory (see, for example, the high simi- intensive delivery modalities, such as in-person
larity between the case formulation principles LGBTQ-affirmative CBT, are reserved for clients
proposed by Coyne et al. (2020) for transgender who do not respond to a more efficient, asyn-
individuals, with those identified by Pachankis chronously delivered version of the treatment
(2014, 2015)), additional research is needed both delivered as a first step, or are perhaps reserved
starting with community consultations with trans- for clients with more acute presenting concerns,
gender and gender nonbinary individuals to iden- whereas group-based and/or online versions of
tify any additional needed principles (Hendricks the treatment are delivered as a first approach to
& Testa, 2012) as well as trials that test the effi- individuals with less acute presentations.
cacy of those distinct principles that might emerge. Finally, implementation-effectiveness research
At the same time, the provision of identity- can identify contextual determinants of low
affirmative CBT to transgender individuals using evidence-based practice penetration–that is, con-
a similar set of overarching principles as has been texts in which therapists who are trained in deliv-
applied to sexual minority individuals suggests the ering LGBTQ-affirmative approaches nonetheless
general utility of this approach (Austin et al., do not utilize these approaches. Identifying rea-
2018; Austin & Craig, 2019; Expósito-Campos sons for therapist reticence as well as situational
et al., 2023). To date, mental health treatment barriers to delivery can guide future training in,
research with gender minority individuals has and adaptation of, LGBTQ-affirmative psy-
more heavily focused on the provision of gender- chotherapies, for example, by specifically address-
affirmative care for youth, and we also refer read- ing therapist concerns or demonstrating how
ers to Huit et al. (2024) for a summary of the state LGBTQ-affirmative approaches can be integrated
of the science in that area. with perhaps more popular approaches in a given
setting.
collecting effectiveness outcomes in
real-world settings identifying presenting concerns for
Now that a significant body of research has estab- which identity-affirming
lished the efficacy of LGBTQ-affirmative psy- psychotherapies are indicated
chotherapies across populations and outcomes, Although the mental health field has generally
the time has come to determine if these effects assumed that identity-specific adaptations of psy-
extend to real-world settings and, if not, what fac- chotherapies are necessary and appropriate
tors might explain the drop in efficacy commonly (Hwang, 2011; Koç & Kafa, 2019), with
found when transitioning interventions from clini- LGBTQ-affirmative adaptations of CBT leading
cal trials to the real-world (Chambers et al., 2013). the way (Craig et al., 2021; Pachankis et al.,
Implementation-effectiveness trials, in particu- 2015a), it remains arguably an open question of
lar, are suited to identifying the generalizability whether identity-focused treatment adaptations
of effects established in randomized controlled tri- are always needed, and as reviewed above, how
als to real-world settings. As applied to LGBTQ- such adaptations should happen if so (Pachankis,
 s t a t e o f t h e s c i e n c e : l g b t q - a f fi r m a t i v e p s y c h o t h e r a p y 1329
2018). Indeed, several studies show that SGM victimization within schools, workplaces, and reli-
individuals derive comparable benefit from general gious settings are likewise associated with poor
psychotherapies as heterosexual and cisgender mental health, such as depression and anxiety
individuals (Beard et al., 2017; Chang et al., (Lefevor et al., 2021; van der Star et al., 2021).
2023). For instance, in a study of 441 participants Even closer to home, SGM individuals are dispro-
in a partial outpatient program, sexual minority portionately likely to experience rejection from
and heterosexual individuals benefitted equally their own families and bullying from peers, with
from standard CBT and DBT treatments, except adverse mental health consequences (la Roi et al.,
for bisexual individuals who had higher levels of 2016; Pachankis et al., 2022). Interventions that
self-injury and suicidal thoughts and worse percep- encourage support and acceptance of SGM indi-
tion of care at posttreatment than the other iden- viduals across these institutions and settings
tity groups (Beard et al., 2017). Another recent appropriately place the onus for change on the
study found no differences in outcomes such as ultimate sources of the sizeable mental health dis-
suicide attempts, general functioning, and treat- parities affecting this population. At the same
ment dropout from DBT delivered in research time, as long as this systemic, structural disadvan-
and community settings when comparing sexual tage exists, interventions such as identity-affirming
minority and heterosexual individuals (Chang psychotherapies that reduce the downstream pro-
et al., 2023). Collectively, this research suggests cesses through which these institutions affect men-
that perhaps general, nonadapted psychotherapies tal health are also justified. Notably, recent
operate sufficiently regardless of sexual and gender research suggests that the efficacy of these down-
identity and that identity-focused adaptations are stream interventions might be shaped by the very
not always needed or are only indicated for certain upstream structural factors whose mental health
presenting concerns. In fact, principles of LGBTQ- harms they seek to remedy. For instance, meta-
affirmative psychotherapy established by the analytic research finds that mental health interven-
American Psychological Association suggest that tions delivered to samples of majority-Black youth
focusing on a client’s sexual or gender identity are less efficacious in U.S. states with greater levels
when such a focus is not warranted by the client’s of anti-Black racism (Price et al., 2022). Whether
presenting concerns would represent distinctly structural stigma similarly impacts the efficacy of
nonaffirmative practice (American Psychological LGBTQ-affirming psychotherapies remains an
Association, 2021). Future research therefore important topic for future study. At the same time,
needs to continue investigating whether and under downstream interventions like psychotherapy
what conditions identity-focused treatments, such might also affect upstream improvements in struc-
as LGBTQ-affirmative CBT, are warranted. Per- tural conditions to the extent that such interventions
haps the strongest test of this question would be a promote SGM visibility and thriving (Cook et al.,
comparative efficacy study of LGBTQ-affirmative 2014), an important question for future research.
psychotherapy, such as LGBTQ-affirmative CBT, Whether the delivery of LGBTQ-affirmative
versus a nonadapted version of the same psy- psychotherapy within settings marked by structural
chotherapy, such as general CBT. However, several stigma can enhance the structural climate of those
challenges exist to conducting such research, settings also remains an open question.
including prodigious sample size requirements
when comparing two active treatments. Conclusion
SGM individuals experience significantly more
integrating lgbtq-affirmative mental health problems than heterosexual and cis-
psychotherapy within structural gender individuals. LGBTQ-affirmative psy-
interventions chotherapy addresses this disparity by targeting
An affirmative approach to SGM mental health characteristic psychological adaptations stemming
recognizes that the source of SGM individuals’ dis- from early and ongoing minority stress. LGBTQ-
proportionate experience of adverse mental health affirmative psychotherapy is effective in addressing
lies not within personal pathology, or even minor- mental health problems for a variety of SGM pop-
ity stress reactions, but rather within structural ulations, across delivery modalities, and in diverse
burdens placed upon the stigmatized geographic and cultural contexts. To maximize
(Hatzenbuehler & Pachankis, 2016). For instance, treatment outcomes and expand the reach of
anti-LGBTQ laws and policies are closely associ- LGBTQ-affirmative psychotherapy, the mental
ated with SGM people’s experiences of depression, health field now needs to understand how this
suicidality, and general well-being (Bränström & therapy works (i.e., treatment mechanisms) and
Pachankis, 2021). Rejection, nonacceptance, and for whom it works best (i.e., treatment modera-
1330 burger & pachankis
tors), test if adaptations to current protocols are Barlow, D. H., & Agras, W. S. (1973). Fading to increase
needed based on these findings, and identify barri- heterosexual responsiveness in homosexuals. Journal of
Applied Behavior Analysis, 6(3), 355–366. [Link]
ers and facilitators of effective implementation 10.1901/jaba.1973.6-355.
across settings. Given the field’s current predomi- Barlow, D. H., Farchione, T. J., Bullis, J. R., Gallagher, M.
nant emphasis on CBT and the conceptual fit of W., Murray-Latin, H., Sauer-Zavala, S., ... Cassiello-
other evidence-based treatment modalities to men- Robbins, C. (2017). The unified protocol for transdiagnos-
tal health mechanisms often experienced by SGM tic treatment of emotional disorders compared with diag-
nosis-specific protocols for anxiety disorders: A
(e.g., emotion suppression, interpersonal role con- randomized clinical trial. JAMA psychiatry, 74(9),
flicts), empirical evidence of LGBTQ-affirmative 875–884.
extensions of other therapeutic orientations is Bauermeister, J., Choi, S. K., Bruehlman-Senecal, E., Golink-
now needed to ensure the full potential reach of off, J., Taboada, A., Lavra, J., Ramazzini, L., Dillon, F., &
LGBTQ-affirmative psychotherapy. The mental Haritatos, J. (2022). An identity-affirming web application
to help sexual and gender minority youth cope with
health field has moved far from the days of pathol- minority stress: Pilot randomized controlled trial. Journal
ogizing assumptions, discourse, and treatments to of Medical Internet Research, 24(8), e39094. [Link]
now possessing increasingly rigorous evidence for org/10.2196/39094.
the efficacy of LGBTQ-affirmative psychothera- Beard, C., Kirakosian, N., Silverman, A. L., Winer, J. P.,
pies. The field’s continued investment in such Wadsworth, L. P., & Björgvinsson, T. (2017). Comparing
treatment response between LGBQ and heterosexual indi-
research and implementation will continue to viduals attending a CBT- and DBT-skills-based partial
ensure this forward progress and the equal thriving hospital. Journal of Consulting and Clinical Psychology, 85
of all SGM clients who seek professional support. (12), 1171–1181. [Link]
Beyrer, C., Baral, S. D., van Griensven, F., Goodreau, S. M.,
Chariyalertsak, S., Wirtz, A. L., & Brookmeyer, R. (2012).
References Global epidemiology of HIV infection in men who have sex
with men. The Lancet, 380(9839), 367–377. [Link]
American Psychiatric Association (2013). Diagnostic and org/10.1016/S0140-6736(12)60821-6.
statistical manual of mental disorders: DSM-5. American Bieber, I., Dain, H. J., Dince, P. R., Drellich, M. G., Grand, H.
Psychiatric Publishing. [Link] G., Grundlach, R. H., Kremer, M. W., Rifkin, A. H.,
9780890425596. Wilbur, C. B., & Bieber, T. B. (1962). Homosexuality: A
American Psychological Association (2015). Guidelines for psychoanalytic study. Basic Books. [Link]
psychological practice with transgender and gender non- 10.1037/11179-000.
conforming people. American Psychologist, 70(9), Bränström, R., Fellman, D., & Pachankis, J. E. (2022). Age-
832–864. [Link] varying sexual orientation disparities in mental health,
American Psychological Association, APA Task Force on treatment utilization, and social stress: A population-based
Psychological Practice with Sexual Minority Persons study. Psychology of Sexual Orientation and Gender
(2021). Guidelines for psychological practice with sexual Diversity. [Link]
minority persons. Retrieved from [Link] Bränström, R., Hatzenbuehler, M. L., Lattanner, M. R.,
about/policy/psychological-practice-sexual-minority-per- Hollinsaid, N. L., McDade, T. W., & Pachankis, J. E.
[Link]. (2024). Threats to social safety and neuro-inflammatory
Antoni, M. H., Carrico, A. W., Durán, R. E., Spitzer, S., Penedo, mechanisms underlying sexual orientation disparities in
F., Ironson, G., Fletcher, M. A., Klimas, N., & Schneiderman, depression symptom severity: A prospective cohort study of
N. (2006). Randomized clinical trial of cognitive behavioral young adults Unpublished manuscript. Solna, Sweden:
stress management on human immunodeficiency virus viral Karolinksa Institute.
load in gay men treated with highly active antiretroviral Bränström, R., & Pachankis, J. E. (2021). Country-level
therapy. Psychosomatic Medicine, 68(1), 143–151. https:// structural stigma, identity concealment, and day-to-day
[Link]/10.1097/[Link].0000195749.60049.63. discrimination as determinants of transgender people’s life
Austin, A., & Craig, S. L. (2019). Transgender affirmative satisfaction. Social Psychiatry and Psychiatric Epidemiol-
cognitive–behavioral therapy. In J. E. Pachankis, S. A. ogy, 56(9), 1537–1545. [Link]
Safren, J. E. Pachankis, & S. A. Safren (Eds.), Handbook of 021-02036-6.
evidence-based mental health practice with sexual and Bränström, R., Pachankis, J. E., Jin, F., Klein, D. N., &
gender minorities. [Link] Hatzenbuehler, M. L. (in press). Self-schemas and infor-
9780190669300.003.0004. mation processing biases as mechanisms underlying sexual
Austin, A., Craig, S. L., & D’Souza, S. A. (2018). An orientation disparities in depressive symptoms: Results
AFFIRMative cognitive behavioral intervention for trans- from a longitudinal, population-based study. Journal of
gender youth: Preliminary effectiveness. Professional Psy- Psychopathology and Clinical Science.
chology: Research and Practice, 49(1), 1–8. [Link] Brooks, V. R. (1981). Minority stress and lesbian women.
10.1037/pro0000154. Lexington Books.
Balsam, K. F., Martell, C. R., & Safren, S. A. (2006). Burger, J. (2023). The Future of Case Formulation: Advances
Affirmative cognitive-behavioral therapy with lesbian, gay, in Network Modeling and Simulation-based Science.
and bisexual people. In Culturally responsive cognitive- University of Groningen.
behavioral therapy: Assessment, practice, and supervision Burger, J., Wang, K., Hollinsaid, N. L., Safren, S. A., &
(pp. 223–243). American Psychological Association. Pachankis, J. E. (2024). Toward a mechanistic understand-
[Link] ing of LGBTQ-affirmative CBT: Testing treatment
 s t a t e o f t h e s c i e n c e : l g b t q - a f fi r m a t i v e p s y c h o t h e r a p y 1331
mediators in a sample of young adult gay and bisexual men 136–144. [Link]
(manuscript in preparation). 022.
Cardona, N. D., Madigan, R. J., & Sauer-Zavala, S. (2022). Craig, S. L., Eaton, A. D., Leung, V. W. Y., Iacono, G., Pang,
How minority stress becomes traumatic invalidation: An N., Dillon, F., Austin, A., Pascoe, R., & Dobinson, C.
emotion-focused conceptualization of minority stress in (2021). Efficacy of affirmative cognitive behavioural group
sexual and gender minority people. Clinical Psychology: therapy for sexual and gender minority adolescents and
Science and Practice, 29(2), 185–195. [Link] young adults in community settings in Ontario, Canada.
10.1037/cps0000054. BMC Psychology, 9(1), 94. [Link]
Chambers, D. A., Glasgow, R. E., & Stange, K. C. (2013). The s40359-021-00595-6.
dynamic sustainability framework: Addressing the paradox D’Augelli, A. R. (1989). Lesbians’ and gay men’s experiences
of sustainment amid ongoing change. Implementation of discrimination and harassment in a university commu-
Science, 8(1), 117. [Link] nity. American Journal of Community Psychology, 17(3),
117. 317–321. [Link]
Chang, C. J., Halvorson, M. A., Lehavot, K., Simpson, T. L., Diamond, G. M., Boruchovitz-Zamir, R., Nir-Gotlieb, O.,
& Harned, M. S. (2023). Sexual identity and race/ethnicity Gat, I., Bar-Kalifa, E., Fitoussi, P., & Katz, S. (2022).
as predictors of treatment outcome and retention in Attachment-based family therapy for sexual and gender
dialectical behavior therapy. Journal of Consulting and minority young adults and their nonaccepting parents.
Clinical Psychology, 91(10), 614–621. [Link] Family Process, 61(2), 530–548. [Link]
10.1037/ccp0000826. 10.1111/famp.12770.
Chaudoir, S. R., Behari, K., Williams, S. L., & Pachankis, J. E. Diamond, G. M., Diamond, G. S., Levy, S., Closs, C., Ladipo,
(2023). Why do brief online writing interventions improve T., & Siqueland, L. (2012). Attachment-based family
health? Examining mediators of expressive writing and therapy for suicidal lesbian, gay, and bisexual adolescents:
self-affirmation intervention efficacy among sexual minor- A treatment development study and open trial with
ity emerging adults. Psychology of Sexual Orientation and preliminary findings. Psychotherapy, 49(1), 62–71.
Gender Diversity, 10(1), 103–116. [Link] [Link]
sgd0000507. Diamond, L. M., & Alley, J. (2022). Rethinking minority
Cochran, S. D., & Mays, V. M. (2000a). Lifetime prevalence stress: A social safety perspective on the health effects of
of suicide symptoms and affective disorders among men stigma in sexually-diverse and gender-diverse populations.
reporting same-sex sexual partners: Results from NHANES Neuroscience & Biobehavioral Reviews, 138, 104720.
III. American Journal of Public Health, 90(4), 573–578. [Link]
[Link] Drescher, J. (2015). Out of DSM: Depathologizing homosex-
Cochran, S. D., & Mays, V. M. (2000b). Relation between uality. Behavioral Sciences, 5(4), 565–575. [Link]
psychiatric syndromes and behaviorally defined sexual 10.3390/bs5040565.
orientation in a sample of the US population. American Expósito-Campos, P., Pérez-Fernández, J. I., & Salaberria, K.
Journal of Epidemiology, 151(5), 516–523. (2023). Empirically supported affirmative psychological
Cohen, J. M., Norona, J. C., Yadavia, J. E., & Borsari, B. interventions for transgender and non-binary youth and
(2021). Affirmative dialectical behavior therapy skills adults: A systematic review. Clinical Psychology Review,
training with sexual minority veterans. Cognitive and 100, 102229. [Link]
Behavioral Practice, 28(1), 77–91. [Link] Fergusson, D. M., Horwood, L. J., & Beautrais, A. L. (1999).
10.1016/[Link].2020.05.008. Is sexual orientation related to mental health problems and
Comer, J. S. (2024). State of the science in behavior therapy: suicidality in young people? Archives of General Psychia-
Taking stock and looking forward. Behavior Therapy, 55 try, 56(10), 876. [Link]
(6), 1101–1113. 876.
Comer, J.S., Georgiadis, C., Schmarder, K., Chen, D., Coyne, Fergusson, D. M., Horwood, L. J., Ridder, E. M., & Beautrais,
C.A., Gudiño, O., Kazantzis, N., Langer, D.A., LeBeau, R. A. L. (2005). Sexual orientation and mental health in a birth
T., Liu, R.T., McLean, C., Sloan, D., Williams, M., & cohort of young adults. Psychological Medicine, 35(7),
Pachankis, J. (2024). Reckoning with our past and righting 971–981. [Link]
our future: Report from the Behavior Therapy Task Force Fish, J. N., King-Marshall, E. C., Williams, N. D., Aparicio, E.
on Sexual Orientation and Gender Identity/Expression M., Tralka, H. M., & Boekeloo, B. O. (2022). What
Change Efforts (SOGIECEs). Behavior Therapy, 15(4), motivates community mental and behavioral health orga-
649–679. [Link] nizations to participate in LGBTQ+ cultural competency
Cook, J. E., Purdie-Vaughns, V., Meyer, I. H., & Busch, J. T. trainings? American Journal of Orthopsychiatry, 92(6),
A. (2014). Intervening within and across levels: A multi- 647–656. [Link]
level approach to stigma and public health. Social Science Fosha, D., & Yeung, D. (2006). Accelerated experiential-
& Medicine, 1982(103), 101–109. [Link] dynamic psychotherapy: The seamless integration of emo-
[Link].2013.09.023. tional transformation and dyadic relatedness at work. In A
Coyne, C. A., Poquiz, J. L., Janssen, A., & Chen, D. (2020). casebook of psychotherapy integration (pp. 165–184).
Evidence-based psychological practice for transgender American Psychological Association. [Link]
and non-binary youth: defining the need, framework for 10.1037/11436-013.
treatment adaptation, and future directions. Evidence- Garcia, J., Vargas, N., Clark, J. L., Magaña Álvarez, M.,
Based Practice in Child and Adolescent Mental Health, Nelons, D. A., & Parker, R. G. (2020). Social isolation and
5(3), 340–353. [Link] connectedness as determinants of well-being: Global evi-
1765433. dence mapping focused on LGBTQ youth. Global
Craig, S. L., & Austin, A. (2016). The AFFIRM open pilot Public Health, 15(4), 497–519. [Link]
feasibility study: A brief affirmative cognitive behavioral 17441692.2019.1682028.
coping skills group intervention for sexual and gender Garofalo, R., Wolf, R. C., Wissow, L. S., Woods, E. R., &
minority youth. Children and Youth Services Review, 64, Goodman, E. (1999). Sexual orientation and risk of suicide
1332 burger & pachankis
attempts among a representative sample of youth. Archives Jackson, S. D., Wagner, K. R., Yepes, M., Harvey, T. D.,
of Pediatrics & Adolescent Medicine, 153(5), 487–493. Higginbottom, J., & Pachankis, J. E. (2022). A pilot test of
[Link] a treatment to address intersectional stigma, mental health,
Glassgold, J. M. (2009). The case of Felix: An example of gay- and HIV risk among gay and bisexual men of color.
affirmative, cognitive-behavioral therapy. Pragmatic Case Psychotherapy (Chicago, Ill.), 59(1), 96–112. [Link]
Studies in Psychotherapy, 5(4), 1–21. [Link] org/10.1037/pst0000417.
10.14713/pcsp.v5i4.995. Johnson, S. M. (2019). Attachment theory in practice:
Goldbach, J. T., Rhoades, H., Mamey, M. R., Senese, J., Emotionally focused therapy (EFT) with individuals, cou-
Karys, P., & Marsiglia, F. F. (2021). Reducing behavioral ples, and families (pp. x, 278). The Guilford Press.
health symptoms by addressing minority stressors in [Link]
LGBTQ adolescents: A randomized controlled trial of Kaysen, D., Lostutter, T. W., & Goines, M. A. (2005).
Proud & Empowered. BMC Public Health, 21(1), 2315. Cognitive processing therapy for acute stress disorder
[Link] resulting from an anti-gay assault. Cognitive and Behav-
Green, R. (1972). Homosexuality as a mental illness. Interna- ioral Practice, 12(3), 278–289. [Link]
tional Journal of Psychiatry, 10(1), 77–98. S1077-7229(05)80050-1.
Greenberg, L. S. (2004). Emotion–focused therapy. Clinical Keefe, J. R., Rodriguez-Seijas, C., Jackson, S. D., Bränström,
Psychology & Psychotherapy, 11(1), 3–16. [Link] R., Harkness, A., Safren, S. A., Hatzenbuehler, M. L., &
10.1002/cpp.388. Pachankis, J. E. (2023). Moderators of LGBQ-affirmative
Hatzenbuehler, M. L. (2009). How does sexual minority cognitive behavioral therapy: ESTEEM is especially effec-
stigma “get under the skin”? A psychological mediation tive among Black and Latino sexual minority men. Journal
framework. Psychological Bulletin, 135(5), 707–730. of Consulting and Clinical Psychology, 91(3), 150–164.
[Link] [Link]
Hatzenbuehler, M. L., Nolen-Hoeksema, S., & Erickson, S. J. Koç, V., & Kafa, G. (2019). Cross-cultural research on
(2008). Minority stress predictors of HIV risk behavior, psychotherapy: The need for a change. Journal of Cross-
substance use, and depressive symptoms: Results from a Cultural Psychology, 50(1), 100–115. [Link]
prospective study of bereaved gay men. Health Psychology, 10.1177/0022022118806577.
27(4), 455–462. [Link] la Roi, C., Kretschmer, T., Dijkstra, J. K., Veenstra, R., &
455. Oldehinkel, A. J. (2016). Disparities in depressive symp-
Hatzenbuehler, M. L., & Pachankis, J. E. (2016). Stigma and toms between heterosexual and lesbian, gay, and bisexual
minority stress as social determinants of health among youth in a Dutch cohort: The TRAILS study. Journal of
lesbian, gay, bisexual, and transgender youth. Pediatric Youth and Adolescence, 45(3), 440–456. [Link]
Clinics of North America, 63(6), 985–997. [Link] 10.1007/s10964-015-0403-0.
10.1016/[Link].2016.07.003. Lefevor, G. T., Boyd-Rogers, C. C., Sprague, B. M., & Janis,
Hatzenbuehler, M. L., & Pachankis, J. E. (2021). Does stigma R. A. (2019). Health disparities between genderqueer,
moderate the efficacy of mental- and behavioral-health transgender, and cisgender individuals: An extension of
interventions? Examining individual and contextual minority stress theory. Journal of Counseling Psychology,
sources of treatment-effect heterogeneity. Current Direc- 66(4), 385–395. [Link]
tions in Psychological Science, 30(6), 476–484. [Link] Lefevor, G. T., Davis, E. B., Paiz, J. Y., & Smack, A. C. P.
org/10.1177/09637214211043884. (2021). The relationship between religiousness and health
Hendricks, M. L., & Testa, R. J. (2012). A conceptual among sexual minorities: A meta-analysis. Psychological
framework for clinical work with transgender and gender Bulletin, 147(7), 647–666. [Link]
nonconforming clients: An adaptation of the Minority bul0000321.
Stress Model. Professional Psychology: Research and Lelutiu-Weinberger, C., Clark, K. A., & Pachankis, J. E.
Practice, 43(5), 460–467. [Link] (2022). Mental health provider training to improve
a0029597. LGBTQ competence and reduce implicit and explicit bias:
Herman, S. H., Barlow, D. H., & Agras, W. S. (1974). An A randomized controlled trial of online and in-person
experimental analysis of classical conditioning as a method delivery. Psychology of Sexual Orientation and Gender
of increasing heterosexual arousal in homosexuals. Behav- Diversity. [Link]
ior Therapy, 5(1), 33–47. [Link] Lelutiu-Weinberger, C., Filimon, M., Chiaramonte, D.,
7894(74)80084-5. Leonard, S., Dogaru, B., Braila, P., Ichim, S., Pana, E.,
Hollinsaid, N. L., Pachankis, J. E., Bränström, R., & Hatzen- Pruneau, C., & Pachankis, J. E. (2024). A pilot trial of
buehler, M. L. (2023). Hypervigilance: An understudied affirming cognitive-behavioral therapy for transgender and
mediator of the longitudinal relationship between stigma gender expansive individuals’ mental, behavioral, and
and internalizing psychopathology among sexual-minority sexual health Unpublished manuscript. New York, NY:
young adults. Clinical Psychological Science. [Link] Columbia University.
org/10.1177/21677026231159050. Lucassen, M. F. G., Merry, S. N., Hatcher, S., & Frampton, C.
Hooker, E. (1957). The adjustment of the male overt homo- M. A. (2015). Rainbow SPARX: A novel approach to
sexual. Journal of Projective Techniques, 21(1), 18–31. addressing depression in sexual minority youth. Cognitive
[Link] and Behavioral Practice, 22(2), 203–216. [Link]
Huit, T. Z., Coyne, C. A., & Chen, D. (2024). State of the 10.1016/[Link].2013.12.008.
Science: Gender-affirming care for transgender and gender MacCulloch, M. J., & Feldman, M. P. (1967). Aversion
diverse youth. Behavior Therapy, 55(6), 1335–1347. therapy in management of 43 homosexuals. British Med-
[Link] ical Journal, 2(5552), 594–597.
Hwang, W.-C. (2011). Cultural adaptations: A complex Maiolatesi, A. J., Wang, K., Burton, C. L., Harkness, A.,
interplay between clinical and cultural issues. Clinical Esserman, D. A., Safren, S. A., & Pachankis, J. E. (2023).
Psychology, 18(3), 238–241. [Link] Rejection sensitivity and sexual minority men’s social
j.1468-2850.2011.01255.x. anxiety disorder: The moderating role of sexual identity
 s t a t e o f t h e s c i e n c e : l g b t q - a f fi r m a t i v e p s y c h o t h e r a p y 1333
strength. Self and Identity, 22(4), 563–591. [Link] Pachankis, J. E. (2015). A transdiagnostic minority stress
10.1080/15298868.2022.2125062. treatment approach for gay and bisexual men’s syndemic
Marshal, M. P., Friedman, M. S., Stall, R., King, K. M., Miles, health conditions. Archives of Sexual Behavior, 44(7),
J., Gold, M. A., Bukstein, O. G., & Morse, J. Q. (2008). 1843–1860. [Link]
Sexual orientation and adolescent substance use: A meta- Pachankis, J. E. (2018). The scientific pursuit of sexual and
analysis and methodological review. Addiction (Abingdon, gender minority mental health treatments: Toward
England), 103(4), 546–556. [Link] evidence-based affirmative practice. The American
j.1360-0443.2008.02149.x. Psychologist, 73(9), 1207–1219. [Link]
Martell, C. R., Safren, S. A., & Prince, S. E. (2004). Cognitive- amp0000357.
behavioral therapies with lesbian, gay, and bisexual clients Pachankis, J. E., Chiaramonte, D., Scheer, J. R., Ankrum, H.,
(pp. xxii, 263–). Guilford Press. Eisenstadt, B. E., Hobbs, R., Baldwin, H., Kidd, J.,
Martos, A. J., Wilson, P. A., & Meyer, I. H. (2017). Lesbian, Witkiewitz, K., Esserman, D., Plourde, K., Drabble, L.,
gay, bisexual, and transgender (LGBT) health services in & Hughes, T. (2024). A randomized controlled trial of
the United States: Origins, evolution, and contemporary LGBTQ-affirmative cognitive-behavioral therapy for sex-
landscape. PLOS ONE, 12(7), e0180544. ual minority women’s minority stress, mental health and
McDanal, R., Schleider, J. L., Fox, K. R., & Eaton, N. R. hazardous drinking: Project EQuIP protocol Unpublished
(2023). Loneliness in gender-diverse and sexual orienta- manuscript. New Haven, CT: Yale University.
tion-diverse adolescents: Measurement invariance analyses Pachankis, J. E., Clark, K. A., Jackson, S. D., Pereira, K., &
and between-group comparisons. Assessment, 30(3), Levine, D. (2021). Current capacity and future implemen-
706–727. [Link] tation of mental health services in U.S. LGBTQ Commu-
McKirnan, D. J., & Peterson, P. L. (1988). Stress, expectan- nity Centers. Psychiatric Services (Washington, D.C.), 72
cies, and vulnerability to substance abuse: A test of a model (6), 669–676. [Link]
among homosexual men. Journal of Abnormal Psychology, Pachankis, J. E., Clark, K. A., Klein, D. N., & Dougherty, L.
97(4), 461–466. [Link] R. (2022). Early timing and determinants of the sexual
461. orientation disparity in internalizing psychopathology: A
McLachlan, C., Nel, J. A., Pillay, S. R., & Victor, C. J. (2019). prospective cohort study from ages 3 to 15. Journal of
The Psychological Society of South Africa’s guidelines for Youth and Adolescence, 51(3), 458–470. [Link]
psychology professionals working with sexually and gen- 10.1007/s10964-021-01532-x.
der-diverse people: Towards inclusive and affirmative Pachankis, J. E., Harkness, A., Jackson, S., Safren, S. A.,
practice. South African Journal of Psychology, 49(3), Pachankis, J. E., Harkness, A., Jackson, S., & Safren, S. A.
314–324. [Link] (2022a). Transdiagnostic LGBTQ-affirmative cognitive-
Medley, B. (2021). Recovering the true self: Affirmative behavioral therapy: Therapist guide. Oxford University
therapy, attachment, and AEDP in psychotherapy with Press.
gay men. Journal of Psychotherapy Integration, 31(4), Pachankis, J. E., Harkness, A., Jackson, S., Safren, S. A.,
383–402. [Link] Pachankis, J. E., Harkness, A., Jackson, S., & Safren, S. A.
Metzger, I. W., Anderson, R. E., Are, F., & Ritchwood, T. (2022b). Transdiagnostic LGBTQ-affirmative cognitive-
(2021). Healing interpersonal and racial trauma: Integrat- behavioral therapy: Workbook. Oxford University Press.
ing racial socialization into trauma-focused cognitive Pachankis, J. E., Harkness, A., Maciejewski, K. R., Behari, K.,
behavioral therapy for African American youth. Child Clark, K. A., McConocha, E., Winston, R., Adeyinka, O.,
Maltreatment, 26(1), 17–27. [Link] Reynolds, J., Bränström, R., Esserman, D. A., Hatzen-
1077559520921457. buehler, M. L., & Safren, S. A. (2022). LGBQ-affirmative
Meyer, I. H. (1995). Minority stress and mental health in gay cognitive-behavioral therapy for young gay and bisexual
men. Journal of Health and Social Behavior, 36(1), 38–56. men’s mental and sexual health: A three-arm randomized
[Link] controlled trial. Journal of Consulting and Clinical Psy-
Meyer, I. H. (2003). Prejudice, social stress, and mental health chology, 90(6), 459–477. [Link]
in lesbian, gay, and bisexual populations: Conceptual ccp0000724.
issues and research evidence. Psychological Bulletin, Pachankis, J. E., Hatzenbuehler, M. L., Klein, D. N., &
129(5), 674–697. [Link] Bränström, R. (2023). The role of shame in the sexual-
5.674. orientation disparity in mental health: A prospective
Millar, B. M., Wang, K., & Pachankis, J. E. (2016). The population-based study of multimodal emotional reactions
moderating role of internalized homonegativity on the to stigma. Clinical Psychological Science. [Link]
efficacy of LGB-affirmative psychotherapy: Results from a 10.1177/21677026231177714.
randomized controlled trial with young adult gay and Pachankis, J. E., Hatzenbuehler, M. L., Rendina, H. J., Safren,
bisexual men. Journal of Consulting and Clinical Psychol- S. A., & Parsons, J. T. (2015a). LGB-affirmative cognitive-
ogy, 84(7), 565–570. [Link] behavioral therapy for young adult gay and bisexual men:
Moras, K. (1993). The use of treatment manuals to train A randomized controlled trial of a transdiagnostic minority
psychotherapists: Observations and recommendations. stress approach. Journal of Consulting and Clinical
Psychotherapy: Theory, Research, Practice, Training, Psychology, 83(5), 875–889. [Link]
30(4), 581–586. [Link] ccp0000037.
581. Pachankis, J. E., Hatzenbuehler, M. L., Rendina, H. J., Safren,
Pachankis, J. E. (2014). Uncovering clinical principles and S. A., & Parsons, J. T. (2015b). LGB-affirmative cognitive-
techniques to address minority stress, mental health, and behavioral therapy for young adult gay and bisexual men:
related health risks among gay and bisexual men. Clinical A randomized controlled trial of a transdiagnostic minority
Psychology: A Publication of the Division of Clinical stress approach. Journal of Consulting and Clinical
Psychology of the American Psychological Association, 21 Psychology, 83, 875–889. [Link]
(4), 313–330. [Link] ccp0000037.
1334 burger & pachankis
Pachankis, J. E., McConocha, E. M., Clark, K. A., Wang, K., Sevelius, J. M. (2013). Gender affirmation: A framework for
Behari, K., Fetzner, B. K., Brisbin, C. D., Scheer, J. R., & conceptualizing risk behavior among transgender women
Lehavot, K. (2020). A transdiagnostic minority stress of color. Sex Roles, 68(11–12), 675–689. [Link]
intervention for gender diverse sexual minority women’s 10.1007/s11199-012-0216-5.
depression, anxiety, and unhealthy alcohol use: A random- Shen, J., Rubin, A., Cohen, K., Hart, E. A., Sung, J., McDanal,
ized controlled trial. Journal of Consulting and Clinical R., Roulston, C., Sotomayor, I., Fox, K. R., & Schleider, J.
Psychology, 88(7), 613–630. [Link] L. (2023). Randomized evaluation of an online single-
ccp0000508. session intervention for minority stress in LGBTQ+ ado-
Pachankis, J. E., Soulliard, Z. A., Layland, E. K., Behari, K., lescents. Internet Interventions, 33, 100633. [Link]
Seager van Dyk, I., Eisenstadt, B. E., Chiaramonte, D., org/10.1016/[Link].2023.100633.
Ljótsson, B., Särnholm, J., & Bjureberg, J. (2023). Guided Sholomskas, D. E., Syracuse-Siewert, G., Rounsaville, B. J.,
LGBTQ-affirmative internet cognitive-behavioral therapy Ball, S. A., Nuro, K. F., & Carroll, K. M. (2005). We don’t
for sexual minority youth’s mental health: A randomized train in vain: A dissemination trial of three strategies of
controlled trial of a minority stress treatment approach. training clinicians in cognitive–behavioral therapy. Journal
Behaviour Research and Therapy, 169, 104403. https:// of Consulting and Clinical Psychology, 73(1), 106–115.
[Link]/10.1016/[Link].2023.104403. [Link]
Pachankis, J. E., Soulliard, Z. A., Morris, F., & Seager Silverstein, C. (2009). The implications of removing homo-
van Dyk, I. (2023). A model for adapting evidence- sexuality from the DSM as a mental disorder. Archives of
based interventions to be LGBQ-affirmative: Putting minor- Sexual Behavior, 38(2), 161–163. [Link]
ity stress principles and case conceptualization into clinical s10508-008-9442-x.
research and practice. Cognitive and Behavioral Practice, Skerven, K., Whicker, D. R., & LeMaire, K. L. (2019).
30(1), 1–17. [Link] 2021.11.005. Applying dialectical behaviour therapy to structural and
Pachankis, J. E., Soulliard, Z. A., Seager van Dyk, I., Layland, internalized stigma with LGBTQ+ clients. The Cognitive
E. K., Clark, K. A., Levine, D. S., & Jackson, S. D. (2022). Behaviour Therapist, 12, e9.
Training in LGBTQ-affirmative cognitive behavioral ther- Socarides, C. W. (1977). Homosexuality. Adam Margrave
apy: A randomized controlled trial across LGBTQ com- Books.
munity centers. Journal of Consulting and Clinical Staples, J. (2023). Exposure therapy with a first-generation,
Psychology, 90(7), 582–599. [Link] Latino transgender man: A dialectical behavior and
ccp0000745. feminist therapy framework. Women & Therapy,
Pachankis, J. E., Williams, S. L., Behari, K., Job, S., 46(2), 152–170. [Link]
McConocha, E. M., & Chaudoir, S. R. (2020). Brief 2226016.
online interventions for LGBTQ young adult mental and Thompson, N. L., McCandless, B. R., & Strickland, B. R.
behavioral health: A randomized controlled trial in a high- (1971). Personal adjustment of male and female homosex-
stigma, low-resource context. Journal of Consulting and uals and heterosexuals. Journal of Abnormal Psychology,
Clinical Psychology, 88(5), 429–444. [Link] 78(2), 237–240. [Link]
10.1037/ccp0000497. van der Star, A., Pachankis, J. E., & Bränström, R. (2021).
Pan, S., Sun, S., Li, X., Chen, J., Xiong, Y., He, Y., & Country-level structural stigma, school-based and adult-
Pachankis, J. E. (2021). A pilot cultural adaptation of LGB- hood victimization, and life satisfaction among sexual
affirmative CBT for young Chinese sexual minority men’s minority adults: A life course approach. Journal of Youth
mental and sexual health. Psychotherapy, 58(1), 12–24. and Adolescence, 50(1), 189–201. [Link]
[Link] s10964-020-01340-9.
Peplau, L. A. (1982). Research on homosexual couples: An Walsh, K., & Hope, D. A. (2010). LGB-affirmative cognitive
overview. Journal of Homosexuality, 8(2), 3–8. [Link] behavioral treatment for social anxiety: A case study
org/10.1300/J082v08n02_02. applying evidence-based practice principles. Cognitive
Price, M. A., Weisz, J. R., McKetta, S., Hollinsaid, N. L., and Behavioral Practice, 17(1), 56–65. [Link]
Lattanner, M. R., Reid, A. E., & Hatzenbuehler, M. L. 10.1016/[Link].2009.04.007.
(2022). Meta-analysis: Are psychotherapies less effective Wilson, S. M., Mulcahy, A. C., Lange, T. M., Eldridge, M. R.,
for Black youth in communities with higher levels of anti- Weidenbacher, H. J., Jackson, G. L., Gierisch, J. M.,
Black racism? Journal of the American Academy of Child Crowley, M. J., Calhoun, P. S., & Hilgeman, M. M.
and Adolescent Psychiatry, 61(6), 754–763. [Link] (2023). Rolling out PRIDE in all who served: Barriers and
10.1016/[Link].2021.07.808. facilitators for sites implementing an LGBTQ+ health
Rosario, M. (2023). Development of lesbian/gay, bisexual, education group for military veterans. Journal of General
and other sexual minority individuals: The closet and Internal Medicine, 38(Suppl 3), 849–856. [Link]
disclosure as a window into the issue. Archives of Sexual 10.1007/s11606-023-08204-5.
Behavior, 52(5), 1923–1929. [Link] Yi, M., Li, X., Chiaramonte, D., Sun, S., Pan, S., Eisenstadt, B.
s10508-022-02516-z. E., Ljótsson, B., Hagaman, A., & Pachankis, J. E. (2024).
Safren, S. A., & Rogers, T. (2001). Cognitive–behavioral Guided internet-based LGBTQ-affirmative cognitive-beha-
therapy with gay, lesbian, and bisexual clients. Journal of vioral therapy: A randomized controlled trial among sexual
Clinical Psychology, 57(5), 629–643. [Link] minority men in China Unpublished manuscript, Yale
10.1002/jclp.1033. University.
Scheer, J. R., Kirsty, A. C., McConocha, E., Wang, K., &
Pachankis, J. E. (2023). Toward cognitive-behavioral RECEIVED: December 12, 2023
therapy for sexual minority women: Voices from stake- ACCEPTED: February 29, 2024
holders and community members. Cognitive and Behav- AVAILABLE ONLINE: 6 MARCH 2024
ioral Practice, 30(3), 471–494. [Link]
cbpra.2022.02.019.