LGBQ-Affirmative Cognitive-Behavioral Therapy for Young Gay and Bisexual Men's Mental and Sexual Health: A Three-Arm Randomized Controlled Trial

Objective: Effective Skills to Empower Effective Men (ESTEEM) represents the first intervention to address the psychological pathways through which minority stress undermines young sexual minority men's (SMM's) mental and sexual health using transdiagnostic cognitive-behavioral therapy. This study compared the efficacy of ESTEEM against two existing interventions. Method: Participants were young human immunodeficiency virus (HIV)-negative SMM (N = 254; ages = 18-35; 67.2% racial/ethnic minority) experiencing a depression, anxiety, and/or stress-/trauma-related disorder and past-90-day HIV transmission risk behavior. After completing HIV testing and counseling, participants were randomized to receive 10-session ESTEEM (n = 100); 10-session community-based lesbian, gay, bisexual, and queer/questioning (LGBQ)-affirmative counseling (n = 102); or only HIV testing and counseling (n = 52). Results: For the primary outcome of any HIV transmission risk behavior at 8 months, ESTEEM was not significantly associated with greater reduction compared to HIV testing and counseling (risk ratio [RR] = 0.89, p = .52). Supportive analyses of the frequency of HIV transmission risk behavior at 8 months showed a nonsignificant difference between ESTEEM compared to HIV testing and counseling (RR = 0.69) and LGBQ-affirmative counseling (RR = 0.62). For secondary outcomes (e.g., depression, anxiety, substance use, suicidality, number of mental health diagnoses) at 8 months, ESTEEM had a larger effect size than the two comparison conditions, but these comparisons did not reach statistical significance when adjusting for the false discovery rate. Observed effect sizes for condition comparisons were smaller than the effect sizes used to power the study. In exploratory analyses, ESTEEM showed promise for reducing comorbidity. Conclusions: Because the control conditions were associated with stronger effects than anticipated, and given the heterogeneous nature of transdiagnostic outcomes, the study possessed insufficient power to statistically detect the consistently small-to-moderate benefit of ESTEEM compared to the two control conditions. What is the public health significance of this article? As long as young sexual minority men (SMM) face minority stress, identity-affirming and effective psychological interventions are needed to address the impact that this stress has on their mental and sexual health. This study found evidence that an lesbian, gay, bisexual, and queer/questioning (LGBQ)-affirmative, minority-stress-focused, transdiagnostic cognitive-behavioral therapy (CBT) intervention called ESTEEM was associated with reductions across numerous mental and sexual health outcomes among young SMM experiencing co-occurring mental and sexual health concerns, though not significantly greater reductions than the two existing interventions to which ESTEEM was compared.