Evidence-Based Approaches to HIV-Positive Sexual Minority Men’s Sexual Health

This chapter reviews the current state of research and theory regarding evidence-based sexual health interventions for HIV-positive sexual minority men. Among HIV-positive sexual minority men, sexual health promotion includes reducing sexual behavior that could lead to HIV transmission, increasing adherence to antiretroviral treatment (ART) medication to attain viral load suppression, and addressing psychosocial and contextual factors that impact both of these health behaviors. The chapter reviews evidence-based behavioral approaches to promote sexual minority men’s sexual health, including those focused on increasing condom use, reducing sexual risk, and improving communication about HIV status. It also discusses interventions to improve ART adherence, which promote HIV-positive sexual minority men’s personal health and serve as a secondary prevention intervention via reducing transmissibility. The chapter concludes with an illustration of an evidence-based intervention with an HIV-positive client. Overarching clinical implications and areas for future research regarding HIV-positive sexual minority men’s sexual health are also discussed.

Evidence-Based Practice for the Prevention and Treatment of Body Image Disturbance and Eating Pathology in Sexual Minority Men

Eating disorders are serious mental health disorders that are associated with significant medical and psychiatric comorbidities, and they have one of the highest mortality rates of any psychiatric disorder. Although considerable research has demonstrated that sexual minority males represent a high-risk group for eating disorders and body image disturbance, less research has been conducted on evidence-based practice for this population. This chapter describes the prevalence of body image disturbance and eating pathology/disorders among sexual minority men. Next, it reviews leading theoretical models that explain these concerns among sexual minority men, including objectification theory, tripartite theory, and sexual minority stress theory. It then discusses clinical interventions and prevention programs tailored to sexual minority men and briefly reviews leading treatment packages for eating pathology in the general population. A case example of enhanced cognitive–behavioral therapy with a hypothetical sexual minority male patient is presented. The chapter concludes with future directions.

Couple Interventions for Same-Sex Couples

This chapter reviews the emerging field of couple interventions for same-sex couples. It outlines the evidence base for couple relationship education and couple therapy based on research with heterosexual couples. It reviews data pertaining to relationship stability and relationship satisfaction of same-sex couples and also the similarities and differences in the predictors of relationship outcomes between heterosexual and same-sex couples. The differences suggest modifications are required, including addressing the role of external influences on couple functioning, the role of dyadic coping to buffer effects of minority stress, non-monogamous relationships, and managing disclosure of one’s relationship. Currently, there is modest uptake of couple services among same-sex couples, and this chapter offers suggestions to enhance the relevance and inclusivity of couple interventions. It concludes by proposing a number of future research directions, including examining the efficacy of couple interventions for same-sex couples and evaluating innovations to increase same-sex couples’ access to services.

Cognitive–Behavioral Therapy for Sexual and Gender Minority Youth Mental Health

Lesbian, gay, bisexual, and transgender (LGBT) youth exist in a developmental context of emerging and shifting identities. This chapter reviews the mental health disparities experienced by LGBT youth. It examines their experiences of minority stress and considers the impact of their family and peer relationships on their identities. Also included is a discussion of affirmative cognitive–behavioral therapy (A-CBT) for LGBT youth, containing detailed clinical examples. The chapter concludes with emerging trends for evidence-based mental health practice with LGBT youth, such as a focus on resilience and the use of information and communication technologies.

Dialectical Behavior Therapy for Borderline Personality Disorder and Suicidality Among Sexual and Gender Minority Individuals

Population-based estimates of borderline personality disorder (BPD) prevalence in lesbian, gay, bisexual, and transgender (LGBT) individuals are lacking. However, epidemiologic data point to high rates of suicidality, including suicide attempts and self-harm, for LGBT individuals—likely due to the high levels of stigma and discrimination that sexual and gender minority individuals experience. The first-line treatment for BPD and suicidal behavior is dialectical behavior therapy (DBT)—a cognitive–behavioral treatment with an emphasis on skills training, based on a biosocial model of disordered behavior—which aims to help clients end suicidal behavior, improve emotion regulation capabilities, and build a “life worth living.” Despite a lack of empirical support, a DBT conceptualization is highly consistent theoretically with the tenets of LGBT-affirmative therapy. This chapter discusses areas of convergence between the biosocial model and the minority stress model, and it presents two case studies of the application of DBT to LGBT clients.

Evidence-Based Alcohol and Substance Use Disorder Treatment with Sexual and Gender Minorities

Although sexual and gender minority (SGM) populations remain at markedly elevated risk for developing alcohol and substance use disorders, relatively few substance use disorder treatment programs provide culturally tailored services. This chapter provides an overview of alcohol and substance use disparities as well as reviews evidence-based interventions in distinct SGM populations. In general, clinical research has focused on culturally tailoring evidence-based substance use disorder treatments such as cognitive–behavioral therapy and motivational interviewing with modest success. Further clinical research should develop and test novel substance use disorder intervention approaches that address minority stress processes as key triggers for unhealthy alcohol consumption and substance use. Clinical research is also needed to address the disparities in unhealthy drinking among sexual minority women as well as alcohol and substance use disparities in transgender individuals. Recommendations are provided to optimize the effectiveness and scalability of existing evidence-based treatments targeting alcohol and substance use disorders in SGM populations.

Evidence-Based Approaches for Treating Depression Among Sexual and Gender Minority Clients

Although depression is one of the most prevalent psychological disorders in the general population, it is even more prevalent in lesbian, gay, bisexual, transgender, and queer (LGBTQ) communities. Psychological treatments for depression have demonstrated efficacy, and this chapter reviews the research literature on depression in sexual minority communities and on the efficacy of treatments. Established treatments for depression do not need to be modified extensively for sexual minority clients. However, particular vulnerabilities need to be taken into account and addressed when working with this population. In this chapter, cognitive, behavioral, and interpersonal therapies for depression are reviewed, and their relevance to work with sexual minority clients is described. The chapter also presents an example of LGBTQ-affirmative cognitive–behavioral therapy for depression.

Affirmative Mental Health Practice with Bisexual Clients

Bisexuals represent the largest sexual minority group, and they experience disproportionate mental and behavioral health risks compared to monosexuals. There is a dearth of psychotherapy and intervention research focused specifically on bisexuals, although evidence-based practice for this population can draw on professional expertise, qualitative and analog research, quantitative descriptive studies, and randomized controlled trials that include bisexual participants. This chapter reviews these literatures and offers guidance for practice and future directions for research. Informed and reflective practice is recommended to develop a strong working alliance, enhance case conceptualization and collaboration, and adapt manualized treatments. Validation, social support, and attention to bisexual-specific mental health stressors may be especially important, given the pervasiveness of binegativity, bisexual stereotypes, and invisibility of bisexuality. Evidence-based practice with this population will be strengthened by future research that specifically investigates bisexuality in mental health practice.

Transgender Affirmative Cognitive–Behavioral Therapy

Although there is growing cultural awareness of transgender identities, transgender people continue to be marginalized and subject to identity-based discrimination and victimization resulting in disproportionate rates of psychological distress and particularly high rates of suicidality. Mental health clinicians can effectively support the mental health needs of transgender clients through the use of empirically supported, trans-affirmative interventions. This chapter focuses on transgender affirmative cognitive–behavioral therapy (TA-CBT), an evidence-informed intervention rooted in the unique needs and experiences of transgender individuals. TA-CBT is a version of CBT that has been adapted to ensure (1) an affirming stance toward gender diversity, (2) recognition of transgender-specific sources of stress and resilience, and (3) the delivery of CBT content within an affirming and trauma-informed framework. Clinical examples are utilized to elucidate affirmative delivery of several important components of TA-CBT: transgender affirmative case conceptualization, psychoeducation, and the development of coping skills to promote identity-affirming changes.

Transdiagnostic Approaches to Improve Sexual Minority Individuals’ Co-occurring Mental, Behavioral, and Sexual Health

Sexual and gender minority individuals are at elevated risk of many adverse psychosocial health outcomes, including mood, anxiety, and substance use disorders, as well as suicidality and sexually transmitted infections. Despite greater utilization of mental health services, there remain few evidence-based approaches specifically tailored for sexual minority individuals and even fewer that are designed to explicitly address the multiple co-occurring conditions that afflict this group. This chapter describes one such approach, rooted in minority stress theory, that has been shown to empirically address the multitude of problematic outcomes and behaviors among sexual minority men and is currently being developed for sexual minority women. The chapter begins by describing the theoretical underpinnings of this therapeutic approach, subsequently providing a description of the major principles underlying this intervention. This chapter ends with an illustrative case example taken from the current clinical trials of this treatment program.