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LGB-affirmative cognitive-behavioral therapy for young adult gay and bisexual men: a randomized controlled trial of a transdiagnostic minority stress approach
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OBJECTIVES: We tested the preliminary efficacy of a transdiagnostic cognitive-behavioral treatment adapted to improve depression, anxiety, and co-occurring health risks (i.e., alcohol use, sexual compulsivity, condomless sex) among young adult gay and bisexual men. Treatment adaptations focused on reducing minority stress processes that underlie sexual orientation-related mental health disparities. METHOD: Young gay and bisexual men (n = 63; M age = 25.94) were randomized to immediate treatment or a 3-month waitlist. At baseline, 3-month, and 6-month assessments, participants completed self-reports of mental health and minority stress and an interview of past-90-day risk behavior. RESULTS: Compared to waitlist, treatment significantly reduced depressive symptoms (b = -2.43, 95% CI: -4.90, 0.35, p < .001), alcohol use problems (b = -3.79, 95% CI: -5.94, -1.64, p < .001), sexual compulsivity (b = -5.09, 95% CI: -8.78, -1.40, p < .001), and past-90-day condomless sex with casual partners (b = -1.09, 95% CI: -1.80, -0.37, p < .001), and improved condom use self-efficacy (b = 10.08, 95% CI: 3.86, 16.30, p < .001). The treatment yielded moderate and marginally significant greater improvements than waitlist in anxiety symptoms (b = -2.14, 95% CI: -4.61, 0.34, p = .09) and past-90-day heavy drinking (b = -0.32, 95% CI: -0.71, 0.07, p = .09). Effects were generally maintained at follow-up. Minority stress processes showed small improvements in the expected direction. CONCLUSION: This study demonstrated preliminary support for the first intervention adapted to address gay and bisexual men's co-occurring health problems at their source in minority stress. If found to be efficacious compared to standard evidence-based treatments, the treatment will possess substantial potential for helping clinicians translate LGB-affirmative treatment guidelines into evidence-based practice. (PsycINFO Database Record
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“condomless anal sex was assessed across the past 30 days rather than over a longer period (Pachankis, Hatzenbuehler, et al., 2015) so as to guard against retrospective recall bias introduced by reporting across longer periods. Yet, this decision might have limited variability in HIV-transmission-risk acts.”
From Guided internet-based LGBTQ-affirmative cognitive-behavioral therapy: A randomized controlled trial among sexual minority men in China (2024) · cites this paper as Pachankis, Hatzenbuehler, et al., 2015
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“Pachankis [33] identified “overarching treatment principles” stemming from the minority stress model, which have been successfully used in interventions designed to address syndemic conditions experienced by gay and bisexual men and alcohol misuse among sexual minority women [34,35].”
From Minority stress theory: Application, critique, and continued relevance (2023) · cites this paper as [35]
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“To the authors’ knowledge, only one randomized controlled trial has been conducted with sexual minority young people to test a CBT-based intervention targeting mental health outcomes—ESTEEM (Effective Skills to Empower Effective Men) [31,32,33].”
From Findings from a feasibility study of an adapted cognitive behavioral therapy group intervention to reduce depression among lgbtq (Lesbian, gay, bisexual, transgender, or queer) young people (2019) · cites this paper as [33]
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“Overall, treatment effects for mental and behavioral problems and minority stress and universal risk factors were in the expected direction and consistent with previous research on LGBTQ-affirmative CBT specifically (Craig, Eaton, et al., 2021; Pachankis, Hatzenbuehler, et al., 2015; Pachankis, McConocha, et al., 2020) and psychosocial interventions focused on sexual minority individuals’ co-occur”
From Guided internet-based LGBTQ-affirmative cognitive-behavioral therapy: A randomized controlled trial among sexual minority men in China (2024) · cites this paper as Pachankis, Hatzenbuehler, et al., 2015
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“We have also incorporated other suggestions from the literature [25,26], where comparable interventions have been successfully tested with the LGBTQ+ community.”
From An Internet-Based Intervention to Increase the Ability of Lesbian, Gay, and Bisexual People to Cope With Adverse Events: Single-Group Feasibility Study (2024) · cites this paper as [26]
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“In studies of men who have sex with men, self-reported compulsive sexual behaviour has been found to be correlated with depression 251 , anxiety 252 , and minority stress (i.e., the stress associated with stigma-related social disadvantage that compounds general life stress) 253 , as well as to be associated with higher rates of sexual risk-taking behaviours 254,255 .”
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“ESTEEM (N = 63) was conducted in New York City and designed specifically for gay and bisexual men aged 18–35 years as the target population [33].”
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“Although the outcome evaluation findings are encouraging in terms of reduced depressive symptoms, alcohol use problems, and sexual risk behaviors”
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“These approaches can be tailored to directly address the cognitive and emotional consequences of discrimination directly, offering SM-YAs practical strategies to rebuild trust, foster resilience, and reengage with their social worlds in healthier, more adaptive ways (Pachankis et al., 2015).”
Craig, S. L., Eaton, A. D., Leung, V. W. Y., Iacono, G., Pang, N., Dillon, F. R., Austin, A., Pascoe, R. V., & Dobinson, C. (2021) · Figshare · doi:10.6084/m9.figshare.14746329
Yang, Y., Ye, Z., Li, W., Sun, Y., & Dai, L. (2024) · Figshare · doi:10.6084/m9.figshare.24934225
Zahran, A., Dermody, S. S., Berlin, G. W., Palma, P. A., Skakoon‐Sparling, S., Noor, S. W. B., Lachowsky, N. J., Grace, D., Cox, J., Moore, D. M., et al. (2024) · Figshare · doi:10.6084/m9.figshare.26686446
Sesenu, F., Kirklewski, S., Takenaka, B. P., Brown, J., Nicholson, E., Haney, K., Carroll, K., Restar, A., Boyd, D. T., Fallin‐Bennett, K., et al. (2025) · JMIR Formative Research · doi:10.2196/76460
“Elevated rates of anxiety and depression among sexually minoritized cisgender men and gender-diverse individuals have also been linked to increased alcohol use, with some research suggesting that these mental health challenges contribute to drinking as a form of self-regulation or coping [29].”
Navigating bias at the frontline: LGBT service employees’ perceived discrimination from customers
Ro, H., & Olson, E. D. (2026) · Strategic Business Research · doi:10.1016/j.sbr.2026.100067
The Well-being of LGBTQ+ People in Czechia During the COVID-19 Pandemic
Pitoňák, M., Fredriksen‐Goldsen, K. I., & Oswald, A. G. (2026) · Sexuality Research and Social Policy · doi:10.1007/s13178-025-01258-6
Jalali, A., Ghasemianrad, M., Khazaie, H., Jalali, R., Chavoshani, F., Khalili, M., & Kazeminia, M. (2026) · SN Comprehensive Clinical Medicine · doi:10.1007/s42399-025-02235-1 · Cited by 2
Krongtham, P., Jaroensuk, P., Choi, E. P. H., & Nhat, T. V. (2026) · Psychology and Sexuality · doi:10.1080/19419899.2026.2632834
Williams, R. S., Johnson, A., Metheny, N., Carrico, A. W., & Flentje, A. (2026) · Archives of Sexual Behavior · doi:10.1007/s10508-025-03319-8
“Without awareness of the proximal–distal minority stress distinction, clinicians risk misattributing symptoms, such as low mood, to a personality or anxiety disorder rather than recognizing them as adaptive responses to chronic stress (Nakamura et al., 2022; Pachankis et al., 2015).”
Access to Health Care by Minorities: Men who establish Homoaffective Relationships
Pasadas, C., & Manso, F. (2022) · International Journal of Nursing · doi:10.15640/ijn.v9n1a2
Fumega, D. F. M., & Stork, M. (2026) · Frontiers in Psychology · doi:10.3389/fpsyg.2026.1800884
“This stance aligns with minority-stress-informed affirmative CBT approaches that acknowledge stigma while targeting proximal processes (e.g., rejection sensitivity, concealment, internalized stigma) in randomized trials with sexual minority samples (Pachankis et al., 2015, 2022).”
Zhou, Y., Zhang, Z., Xiang, F., Xu, M., & Zhou, Z. (2026) · Scientific Reports · doi:10.1038/s41598-026-46302-6
Wu, W., Song, X., Pachankis, J. E., Yi, M., Li, M. L., Pan, S., He, Y., Li, F., Xiong, Y., & Li, X. (2026) · doi:10.2196/preprints.98541
Self-citationYu, J., & Liang, Z. (2026) · Psychology and Psychotherapy Theory Research and Practice · doi:10.1111/papt.70068
“Studies have shown that IH may decline, remain stable or increase across time and that these trajectories correspond to differences in mental health outcomes (Herrick et al., 2013; Pachankis et al., 2015; Puckett et al., 2018).”
Gleason, N., Wang, S. S., Smith, L., Rahm-Knigge, R. L., Coleman, E., & George, W. H. (2026) · Sexual Health & Compulsivity · doi:10.1080/26929953.2026.2673332
Harper, K. L., Kelton, K., Livingston, N. A., Iverson, K. M., Sloan, C. A., Batchelder, A., & Marx, B. P. (2026) · Contemporary Clinical Trials Communications · doi:10.1016/j.conctc.2026.101650
“These stress responses contribute to increased risk of anxiety and depression, which in turn explain risk for high-risk health behaviors (e. g., substance use and suicide) [13].”
Jaipuriyar, V., Behari, K., Rashkovsky, K. T., Girard, R., Sherman, A. L., Chasten, N. T., Epshteyn, G., Lee, J., Helminen, E. C., & Scheer, J. R. (2026) · Contemporary Clinical Trials Communications · doi:10.1016/j.conctc.2026.101666
“This pilot study therefore draws on UP Modules 2 – 5, which target emotional awareness, cognitive flexibility, maladaptive coping patterns, and emotion-driven behaviors that sustain hazardous drinking, post-traumatic stress, and stigma-related distress [25,48,62,70].”
Metadata
- Authors
- Pachankis, J. E., Hatzenbuehler, M. L., Rendina, H. J., Safren, S. A., & Parsons, J. T.
- Affiliations
- Yale University (US)
- Columbia University (US)
- Harvard University (US)
- ORCID
- Venue
- Journal of Consulting and Clinical Psychology
- Published
- 2015-10
- Volume
- 83
- Issue
- 5
- Pages
- 875-889
- ISSN
- 0022-006X (ISSN-L)
- 1939-2117
- PMC
- PMC4573250
- OpenAlex
- W2274662974
- Cited by
- 619
- References
- 67
- Citations by year
- 2026: 41 · 2025: 54 · 2024: 66 · 2023: 56 · 2022: 87 · 2021: 60 · 2020: 67 · 2019: 70 · 2018: 45 · 2017: 45 · 2016: 22 · 2015: 6
- FWCI
- 64.36
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Locations
- Journal of Consulting and Clinical Psychology (publishedVersion, other-oa)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institute of Mental Health (R34-MH096607, K24 MH094214)
- Topics
- Social Sciences › Psychology › Social Psychology › LGBTQ Health, Identity, and Policy
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Health Sciences › Medicine › Infectious Diseases › HIV/AIDS Research and Interventions
- Keywords
- minority stress, gay and bisexual men, young men, depression, anxiety, alcohol consumption, compulsive sexual behavior, unprotected sex, condom use self-efficacy, transdiagnostic treatment, cognitive behavioral therapy, health risk behaviors, treatment efficacy, waitlist control, sexual minority mental health
- MeSH terms
- Adolescent, Adult, Mental Disorders, Bisexuality, Follow-Up Studies, Humans, Male, Minority Groups, Risk-Taking, Stress, Psychological, Cognitive Behavioral Therapy, Treatment Outcome, Homosexuality, Male, Young Adult, Self Report
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