Last fall's election of openly transgender Danica Roem to the Virginia Senate was another step forward for the rights of lesbian, gay, bisexual and transgender (LGBT) people in the United States. But despite such successes, many LGBT people continue to struggle with harassment and other forms of social stigma, which research shows is associated with mental health problems. The LGBT population has far higher rates of depression, anxiety, substance use and suicide than their heterosexual and cisgender counterparts.
And unfortunately, evidence-based mental health interventions for LGBT people have been virtually nonexistent, says clinical psychologist John Pachankis, PhD, who heads the Esteem Program at Yale University's School of Public Health. "There has been this tragic lack in science, where we've taken much longer than we should have to create and deliver interventions that can reduce these mental health disparities," he says.
Pachankis, who earned his doctorate from the State University of New York at Stony Brook in 2008, says this work began to grip him as a graduate student, when he was providing therapy to gay and bisexual men in New York. "There was no clear guidance on how to support these men in some of the unique difficulties they were going through," he recalls.
To try to address that gap, Pachankis and his lab combine psychological and public health approaches to learn about and address the stigma-related mental health issues that they are finding among people in their studies. The lab—which has dual locations in New Haven, Connecticut, and New York City—includes about 15 team members who are a mix of postdoctoral fellows, graduate students and undergraduates working in public health, psychology or both.
The group's largest project is developing and studying ESTEEM (Effective Skills to Empower Effective Men), an evidence-based intervention for young gay and bisexual men at risk for HIV infection.
In addition, the lab is examining the intersection of physical health, mental health and stigma among lesbian and bisexual women, LGBT people in underserved areas and transgender women in prison.
Most of the lab's work is funded by a grant from the National Institute of Mental Health (NIMH); other projects are funded by Yale's Fund for Lesbian and Gay Studies, Yale faculty incentive funding, and smaller grants from NIMH and the Fogarty International Center at the National Institutes of Health.
Sexual minority men
The rationale behind ESTEEM is to address ways that internalized stigma and homophobia may cause sexual minority men to think, act and feel in ways that undermine their physical and mental health. If a gay man is experiencing significant levels of stigma-related unconscious shame, for example, he might be tempted to mask the pain by having compulsive sex, drinking too much or overworking.
To tackle participants' issues in these areas, Pachankis and colleagues have developed a 10-session treatment derived from the unified protocol for treating anxiety, depression and other mood disorders developed by Boston University psychologist David Barlow, PhD, and adapted to this group's stigma-based stress. Through the intervention, therapists help participants identify minority stress experiences—instances of being rejected based on their sexual orientation, for example—and track their cognitive, affective and behavioral reactions to this stress. The providers then help the men build healthy counter-thoughts and behaviors, such as learning to attribute their distress to minority stress rather than to personal failure, and to become more assertive and self-affirming.
The intervention involves screening for depression and anxiety disorders and substance abuse, lengthy clinical interviews that identify areas to target, the intervention itself and periodic outcome assessments for a year after treatment. The team also measures HIV-risk behaviors and sense of self-worth.
The team's pilot project showed that the intervention was successful in reducing depression, alcohol overuse, having sex without condoms and sexual compulsivity (Journal of Clinical and Consulting Psychology, Vol. 83, No. 5, 2015).
Now, together with a research team at the University of Miami headed by Steven A. Safren, PhD, several members of Pachankis' team are halfway through a five-year randomized controlled trial comparing how 250 men in New York and Miami fare after receiving ESTEEM, community treatment as usual, or brief HIV testing and counseling.
In another research effort, the lab has found that sexual minority men experience stigma-related stress from members of their own communities—for example, scrutiny based on appearance, financial status, sexual desirability and other external features. In surveys and experimental studies, postdoctoral fellow Charles Burton, PhD, and Pachankis are showing that this within-community stress is as likely to cause mental health problems as other forms of minority stress. The two are now looking into how this phenomenon might influence men's depression and sexual risk-taking behavior.
"It's important work," says Burton, "because most clinicians are not aware of the emotional and physical health significance of a community that, for many sexual minority clients, is both a source of support and stress."
Addressing lesbian and transgender needs
Other team members are looking into ways that stigma may affect the mental health and health behavior of sexual minority women and transgender individuals.
Erin McConocha, a public health master's student in the school's social and behavioral sciences program, is using Pachankis' basic study design to develop a therapy program for sexual minority women called EQuIP—Empowering Queer Identities in Psychotherapy. To develop the intervention, she is interviewing 20 sexual minority women about their experiences with stigma, depression, suicidality and alcohol overuse, and getting input from 10 psychologists across the country who McConocha has identified as expert clinicians based on their scholarly publications and professional reputations in working with sexual minority women. Like Pachankis, she is drawing themes from those interviews to inform the intervention, and she and the team will also use Barlow's unified protocol as a starting point.
Meanwhile, team member and epidemiologist Jaclyn White Hughto, has been focusing on a particularly vulnerable segment of the LGBT community: transgender women in prison. Her dissertation, now in press, combines qualitative and quantitative work to assess and intervene in this population's health care. Her first step was to interview transgender women about their health care experiences while incarcerated.
Next, she and a former member of the lab, Kirsty Clark, now earning her doctorate at the University of California, Los Angeles, talked with correctional health-care providers to gain their perspectives on caring for these patients. Based on that work, White Hughto then adapted an educational intervention to improve correctional providers' cultural and clinical competency in providing transgender care, and in 2016, she and Clark trained 100 providers in the model. At a three-month follow-up, White Hughto documented that providers had improved significantly in their willingness and ability to provide such care. Now she is eager to assess the impact of the training on both providers and inmates. She also wants to develop online training video segments of transgender inmates.
"We know that these online trainings can be very dry when you have to read through a lot of content," she says. "So, having something visual and engaging is one of my goals."
Intervening with the underserved
LGBT individuals in low-resource and rural settings tend to face greater stigma and be more closeted than those in urban areas, and team members want to intervene there, too. In a project funded by NIH's Fogarty International Center, Pachankis and social psychologist Corina Lelutiu-Weinberger, PhD, of Rutgers University, are conducting a pilot study of a mobile therapy intervention delivered to about 60 young gay and bisexual men in Romania—one of the few Eastern European countries where the rate of new HIV/AIDS cases among this population is increasing. Therapists provide real-time LGBT- affirmative motivational and cognitive-behavioral therapy via smartphones and other mobile devices. The devices can also be used to track mood, alcohol use and risky sexual behavior, and those results can be used in therapy discussions. In a related project funded by NIMH, the team is also training 180 therapists to deliver LGBT-affirmative mental and behavioral health-care across Romania, including in small towns.
"The idea behind providing therapist training as well as the mobile intervention is to ensure there is adequate support on the ground to continue the mobile treatment once the grant is finished," Pachankis says.
In a similar type of study in the United States, members of Pachankis' team are working with partners at East Tennessee State University in Johnson City, Tennessee, and the College of the Holy Cross in Worcester, Massachusetts, to deliver low-cost writing interventions to rural LGBT youth. One intervention instructs participants to advise a person being discriminated against based on their sexual orientation; the other encourages them to write about the most stressful experiences they've faced due to their status.
These interventions "have been shown to be effective in reducing mental health concerns and to some extent risk behavior, so we want to see how they work among LGBT young adults in rural Appalachia and other high-stigma places," says the lab's senior research assistant, T.J. Sullivan, who has worked in Pachankis' lab for two years and is now applying to psychology doctoral programs.
For his part, Pachankis is heartened by his team's progress toward his long-standing goal of improving LGBT health and mental health through evidence-based interventions. But he's also interested in a broader aim: He'd like to use psychological research to create a more valid picture of LGBT mental health, a topic that's been muddied over the years by politics and such harmful interventions as conversion therapy. Even well-meaning research of the past, such as Evelyn Hooker's studies in the 1950s arguing that LGBT people's psychological profiles are indistinguishable from those of straight people, need an update, he says.
"We now know, for example, that LGBT people are more affected by mental health problems than heterosexuals, but it's because of stigma-related stress," Pachankis says. "We're finally in a position, historically, where we can use high- quality science to arrive at a more accurate truth about LGBT people's lives, and how their unique experiences shape their mental health."
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Research foci
The ESTEEM Lab's work includes focusing on:
- Young gay and bisexual men at risk for HIV infection.
- Transgender women in prison.
- Mental health and health behavior of sexual minority women and transgender individuals.
See the full list of research projects at https://esteem.yale.edu/projectsopens in new window.
