Toward a mechanistic understanding of LGBTQ-affirmative cognitive-behavioral therapy: Testing treatment mediators in...

Young gay and bisexual men (YGBM) face elevated risk for co-occurring mental (e.g., depression, anxiety), behavioral (e.g., substance use), and sexual (e.g., HIV-transmission-risk behavior) health challenges compared to their heterosexual peers. LGBTQ-affirmative cognitive-behavioral therapy (CBT) targets psychosocial pathways through which minority stress is hypothesized to contribute to these disparities. We evaluated whether LGBTQ-affirmative CBT operates through these candidate mechanisms.

We analyzed trial data from 254 HIV-negative YGBM (ages 18-35; 67.2 % racial/ethnic minority) with mental, behavioral, and/or sexual health concerns randomly assigned to receive LGBTQ-affirmative CBT or one of two control conditions: LGBTQ-affirmative community counseling or HIV testing and counseling. Using baseline and 4-, 8-, and 12-month follow-up assessments, trajectories of identity-specific (i.e., sexual orientation-related acceptance concerns, concealment motivation, and internalized stigma) and general (i.e., assertiveness, emotion regulation difficulties, rumination, self-esteem, and social support) mechanisms were examined. Additionally, latent change score structural equation models tested whether these mechanisms mediated the relative impact of LGBTQ-affirmative CBT (vs. control) on depression, anxiety, substance use, HIV-transmission-risk behavior, or their co-occurrence.

Across the LGBTQ-affirmative CBT and control conditions, participants showed improvements in all mediators and clinical outcomes. While no formal mediation effects were detected, improvements in sexual orientation-related acceptance concerns were associated with improvements in problematic substance use across conditions, suggesting that this process may represent one promising target irrespective of treatment condition.

Identifying treatment mechanisms may help to maximize the efficacy of LGBTQ-affirmative CBT. While no definitive mediators emerged in this study, the consistent improvement across all candidate processes underscores their potential importance. Our findings highlight several challenges in establishing mechanisms of LGBTQ-affirmative CBT, including statistical power, active comparators, and measurement. We provide recommendations for advancing mechanistic tests in future work.