Yale Psychiatry Grand Rounds: October 28, 2022

Transcript

• 00:00For the for the invitation to be here today,
• 00:03to just speak to you all in the Department
• 00:07of Psychiatry about this increasingly
• 00:11important and increasingly visible.
• 00:14Topic and that is how to go about
• 00:18providing care to our LGBTQ clients and
• 00:21patients and how we can do that and
• 00:25scientifically informed evidence based
• 00:27ways and the mental health that you
• 00:30can say crisis affecting LGBTQ people
• 00:33and populations is one of the the the
• 00:35most pressing concerns of the LGBTQ
• 00:38community in the US and around the world.
• 00:40So it's really an honor and and and
• 00:43and often feels like an imperative.
• 00:45To to do this work to figure out how we
• 00:49can do do do best by our LGBTQ clientele.
• 00:52The the challenge the.
• 00:57Unity is quite simply defined,
• 00:59and it's that LGBTQ people represent one of
• 01:01the highest risk groups of any population.
• 01:03Risk groups for depression,
• 01:05anxiety, substance use problems,
• 01:07and suicidality.
• 01:08And now that we have high quality,
• 01:11nationally representative datasets
• 01:12that actually assess sex orientation
• 01:14and gender identity,
• 01:15diverse gender identities,
• 01:16something we didn't have until
• 01:18until surprisingly recently,
• 01:20we know that study after study
• 01:22has shown that LGBTQ people,
• 01:23or at least twice greater risk of
• 01:25of these mental health outcomes.
• 01:27And heterosexual cisgender populations.
• 01:29We also know that this disparity
• 01:31largely persists across the life course.
• 01:34This is true in nearly eight every
• 01:35data set in every country in
• 01:36which this has been examined,
• 01:38although most of these datasets are
• 01:40are are in more Westernized context.
• 01:42I want to address this challenge
• 01:44today in two broad parts.
• 01:45The first,
• 01:46we'll focus on the theoretical causes
• 01:47of this disparity and the second we'll
• 01:49focus on on on potential solutions
• 01:51to this disparity largely through
• 01:53research taking place at Yale.
• 01:55It's involving clinical trials and.
• 01:57Imitation science of of of LGBTQ
• 02:01affirmative cognitive behavioral therapy.
• 02:03Which is the first evidence based
• 02:05treatments developed by and for
• 02:07LGBTQ people's mental health.
• 02:09So we know that the most plausible
• 02:11cause of the mental health
• 02:12disparities affecting LGBTQ people
• 02:14is not biological or genetic.
• 02:16Is is is some people have argued,
• 02:18but rather probably stigma or simply
• 02:20the societal conditions that lead
• 02:22some people to be actively devalued
• 02:24and have less power than others.
• 02:262 prominent types of stigma that we
• 02:29can consider are the discriminatory
• 02:31societal structures that surround.
• 02:33Many minoritized groups called
• 02:36structural stigma.
• 02:37And also the stressful kind of more
• 02:40daily encounters with stigma that that
• 02:42happened in our interactions with
• 02:44other people, including strangers,
• 02:45peers, coworkers,
• 02:46and even prominently in the in
• 02:49the case of LGBTQ people,
• 02:50even from their own families.
• 02:51We'll call this interpersonal stigma,
• 02:53but we'll start with structural stigma,
• 02:55which is defined as unjust laws,
• 02:57policies,
• 02:57and community attitudes that deny
• 02:59or fail to protect the equal rights
• 03:01of the stigmatized.
• 03:02Until recently,
• 03:03though,
• 03:04structural stigma has been difficult
• 03:05to measure because it requires a few things.
• 03:08One is that you have large samples
• 03:10of the LGBTQ population,
• 03:11which as I said earlier have
• 03:13been have been relatively
• 03:15hard to come by.
• 03:16We also need the LGBTQ sample to
• 03:19have been recruited from from from
• 03:22geographically diverse structural context.
• 03:25You know most of our our studies
• 03:27especially with minoritized populations
• 03:28come from like 1 context like one
• 03:31community like New Haven or one college
• 03:32like Yale without much structural
• 03:34diversity and in the in the surroundings.
• 03:38And so we need to study the
• 03:40influence structural stigma,
• 03:40we need context with diverse structures
• 03:42and we also need an approach to
• 03:45quantifying structural stigma,
• 03:47those laws and policies that
• 03:49surround TQ people.
• 03:50Such a quantitative index might look
• 03:52like this where you can sum each
• 03:55country's present each country.
• 03:56I said, because I'll talk about
• 03:58doing this internationally first.
• 04:00You can send each country's presence
• 04:02or absence of discriminatory
• 04:04criminalizing laws and policies
• 04:06and also the those countries.
• 04:07Protective laws and policies and this
• 04:10objective approach to measuring stigma
• 04:13and also overcomes the limitations
• 04:15are more commonly used subjective
• 04:18measurements of stigma which we know
• 04:20are subject to the same source or to
• 04:22self report bias in which two people
• 04:24can have very different experiences
• 04:26of the same discriminatory event.
• 04:28Using an objective measure of
• 04:30structural stigma also overcomes
• 04:32limitations of same source reporting
• 04:34bias whereby the predictor and
• 04:35this case stigma and the outcome.
• 04:37Were measured using the same approach
• 04:39by asking people the perceptions of
• 04:41stigma and in their own mental health,
• 04:43which can produce artificially
• 04:44inflated estimates of the associations
• 04:46between those things.
• 04:47But using a quantitative,
• 04:48objective assessment of structural
• 04:50stigma like this overcomes at
• 04:52least those two limitations.
• 04:53So such an index can then be applied
• 04:56to suitable data opportunities.
• 04:58The EU LGBT survey and and also the
• 05:01European men who have sex with men
• 05:04Internet survey represent the two
• 05:06largest in terms of sample size.
• 05:09Datasets ever collected the LGBTQ
• 05:13population these datasets allow
• 05:15because they span such diverse
• 05:18context from countries like like
• 05:20Sweden and where I am right now,
• 05:22having about the lowest stigma,
• 05:25structural stigma towards LGBTQ
• 05:27people possible being at the vanguard
• 05:29of LGBT rights kind of right next
• 05:31door to countries like like like
• 05:34Romania or Hungary or Poland,
• 05:36which are some of the most
• 05:38stigmatizing countries.
• 05:39In the EU,
• 05:40where same sex marriage isn't allowed,
• 05:41where where you can't update your
• 05:43gender identity on unofficial
• 05:45documents and things like this,
• 05:46so you have this patchwork of of a
• 05:49very diverse kind of structural context,
• 05:51really sitting right next to each other.
• 05:52And importantly, we have data.
• 05:58The populations living in those
• 06:00countries and in these datasets we
• 06:02see a strong association between
• 06:04country level structural stigma
• 06:05with this countries on the right,
• 06:07countries like Lebanon and Belarus,
• 06:09Ukraine being very high in
• 06:11terms of structural stigma,
• 06:13which countries on the left,
• 06:14countries like Netherlands,
• 06:14Denmark, Austria being very
• 06:16low on the on on that index,
• 06:18you see across that a strong linear
• 06:21association between the prevalence of
• 06:23of depression and the LGBTQ population.
• 06:26And structural stigma.
• 06:27Now these estimates are even controlling
• 06:29for average country level depression
• 06:31where people in in Lebanon have
• 06:33higher higher risk of depression in
• 06:35general than people in the Netherlands.
• 06:37Even over and above that
• 06:39you see that LGBT people.
• 06:42Um, risk of depression is um
• 06:44is is a strong linear function
• 06:47of of of the structural legal
• 06:50policy climate surrounding them.
• 06:54This is the same is true of suicidality,
• 06:56with about 15% of LGBTQ people
• 06:58in the Netherlands reporting
• 07:00past year suicidality on the PHQ,
• 07:02where's twice that percent of LGBTQ
• 07:04people report past year suicidality and
• 07:06more structurally stigmatizing context
• 07:08like like Belarus or North Macedonia.
• 07:10Again, this is over and above the fact that,
• 07:14that, that, that, that,
• 07:15that there's a higher prevalence,
• 07:17the depression,
• 07:17and in the general population and some of
• 07:20those more structurally stigmatizing context.
• 07:22So now I'll present.
• 07:24Evidence that interpersonal stigma,
• 07:25including interpersonal interactions with
• 07:27parents and peers due to ones LGBTQ status,
• 07:31predict the mental health outcomes known to
• 07:34just disproportionately affect LGBTQ people.
• 07:36Now the search for these interpersonal
• 07:38forms of stigma has to start early because
• 07:41we know that many young LGBTQ people
• 07:44experience mental health challenges.
• 07:46But how young and how much LGBTQ people?
• 07:49Young people disproportionately
• 07:50experience mental health challenges like
• 07:53depression compared to heterosexual,
• 07:55cisgender young people?
• 07:56It's still relatively unclear,
• 07:58largely because of the challenges of studying
• 08:00these topics among very young people.
• 08:02So my colleague Dan Klein at SUNY Stony
• 08:05Brook has been prospectively following
• 08:07a group of about 600 youth since they
• 08:10were aged 3 on Long Island, New York.
• 08:13The study started when I was in Graduate
• 08:14School at Stony Brook and every three years.
• 08:16Match that time,
• 08:17the the youth and their parents and
• 08:19teachers completed numerous assessments,
• 08:21including interviews including
• 08:23EG of you know of, of,
• 08:26of, of.
• 08:28Developmental and temperamental precursors
• 08:30to depression and then depression itself.
• 08:32As the kids aged a few years ago,
• 08:34we received support from NIH to to
• 08:36to study the timing and causes of
• 08:39the sexual orientation disparity and
• 08:41mental health problems in the sample.
• 08:43We started by asking the youth at age
• 08:4515 what gender they were attracted to.
• 08:48This allowed us to assess who
• 08:50probably is was being gay or bisexual,
• 08:53at least in terms of the gender
• 08:54or genders to which they reported
• 08:56being attracted,
• 08:56and in that sample about 11% of the youth.
• 08:59Did report same gender attractions and
• 09:01in their lives they had experienced
• 09:03a steep relative increase in
• 09:05depression and compared to other
• 09:06gender attractive youth from a
• 09:08pretty early age, with that disparity
• 09:11becoming quite pronounced by by
• 09:13by middle school and high school.
• 09:16By high school, we also see
• 09:17that many more of the youth
• 09:19recorded same gender attractions,
• 09:20reported poor relationships
• 09:22with their parents,
• 09:23and reported more bullying compared
• 09:24to youth through reported only being
• 09:26attracted to the other the other gender.
• 09:28In fact, the association between sexual
• 09:31orientation and age 15 depression was
• 09:33significantly mediated by age 12 exposure
• 09:36to poor relationships with parents and
• 09:38to exposure to to bullying from their peers.
• 09:41So results like this highlight the potential
• 09:44role of interpersonal stigma from.
• 09:46From,
• 09:46from parents and peers and LGBTQ peoples.
• 09:49Disproportionate exposure of depression.
• 09:51So these findings regarding structural
• 09:54stigma and interpersonal stigma,
• 09:56of which I just presented some some
• 09:59more recent analysis of of many,
• 10:01support the basic tenets of what's
• 10:03known as minority stress theory.
• 10:05Minority stress theory suggests that
• 10:07the causes of the sexual and gender
• 10:10minority disparity in mental health and
• 10:13related outcomes is a function of LGBTQ
• 10:15people's greater exposure to to stigma.
• 10:18Structural stigma interpersonal stigma,
• 10:19another key part of minority stress theory.
• 10:22Is that these forms of stigma give
• 10:24rise to minority stress reactions that
• 10:26serve as mediators of the association
• 10:29between stigma and poor mental health.
• 10:31But what's the minority stress reaction?
• 10:33Well,
• 10:33one of the reactions that I've
• 10:35spent a good deal of time studying
• 10:37is identity concealment.
• 10:39So because they possess a
• 10:41relatively concealable stigma,
• 10:42LGBT people face the choice of
• 10:44whether or not to come out.
• 10:46And although models of stigma
• 10:48concealment suggest that the
• 10:50environment should ultimately determine.
• 10:53An LGBTQ persons person.
• 10:55So.
• 10:59Or or cost of concealment versus coming out.
• 11:01Very few studies have have
• 11:03actually examined the environment.
• 11:04Is A is A is a determinant of concealment.
• 11:06So using the same large cross country
• 11:08EU data set that I mentioned earlier,
• 11:11we found that in countries like the UK
• 11:13that scored low on structural stigma,
• 11:15the vast majority like 90%
• 11:17of LGBTQ people are out.
• 11:19In countries like Romania that
• 11:20scored higher on this index,
• 11:22the majority of section minority
• 11:23people are actually in the closet.
• 11:24They say that they've told very few
• 11:26people are or know people in their lives.
• 11:28With their LGBTQ and and again you
• 11:30see a strong linear association
• 11:32between between really how LGBTQ
• 11:34people live their lives.
• 11:36I mean this isn't you know this
• 11:38isn't abstract this this is you know
• 11:41consuming is something that that that
• 11:43that affects the day-to-day decisions
• 11:45the day-to-day self presentation how
• 11:47what people share what they choose
• 11:50to silence within themselves and we
• 11:52know that the concealment can not only
• 11:54take a mental health toll especially.
• 11:56Didn't see one about a personally
• 11:59important aspect of oneself.
• 12:00And again,
• 12:01you have you have people living
• 12:03basically right next door to each other.
• 12:05Um, depending, you know,
• 12:07countries like like countries like
• 12:10Sweden being right next door to,
• 12:12to,
• 12:13to countries like Russia or
• 12:14Ukraine or Belarus,
• 12:16where the the lived experience of
• 12:17LGBTQ people in terms of this one
• 12:19factor concealment looks very,
• 12:21very different with them with with,
• 12:23with actually concomitant impacts on,
• 12:26on mental health.
• 12:27Because in fact we see that the
• 12:29association between structural
• 12:30stigma and outcomes like suicidality
• 12:33are significantly mediated by
• 12:35by how much people conceal.
• 12:36The same is true for internalized stigma
• 12:40or the direction of negative societal
• 12:43attitudes towards the towards the South.
• 12:46So this is like responding to to question
• 12:48like I wish I could be straight,
• 12:51if I could take a pill to to
• 12:53be heterosexual I would.
• 12:54That's the type of items that that
• 12:56indicate internalized stigma and
• 12:58again you see a similar association
• 12:59between country level structural
• 13:00stigma and that type in that
• 13:02type of outcome and a similar
• 13:04mediation mediation association.
• 13:06I mean structural stigma,
• 13:07internalized stigma and and outcomes
• 13:10like depression and anxiety.
• 13:12So the final minority stress reaction
• 13:15that that that we've examined
• 13:18is called rejection sensitivity.
• 13:19So rejection sensitivity is the
• 13:21tendency to anxiously expect
• 13:23and severely react to rejection
• 13:25among stigmatized populations.
• 13:27Rejection sensitivity is understood
• 13:29to be an interpersonal schema
• 13:31that emerges and upon repeated
• 13:33exposure to stigma based rejection.
• 13:36And we studied sexual orientation
• 13:38differences and rejection
• 13:39sensitivity in that,
• 13:40in that longitudinal study from
• 13:41Stony Brook that I mentioned earlier,
• 13:43the the the 500 or so youth
• 13:46on Long Island at age 15,
• 13:48those youth completed a
• 13:49game called Island Getaway.
• 13:51It's like based on the TV show Survivor,
• 13:53whereby participants are told they're
• 13:55traveling through the Hawaiian Islands,
• 13:57they share a little about themselves.
• 14:01And then are voted on by their
• 14:03peers as they
• 14:04themselves vote for the peers that
• 14:06they want to proceed or kick off
• 14:08and to to move to the next island.
• 14:10Unbeknownst to the participant and the
• 14:12other kids were all computer generated,
• 14:15but there was a good cover story
• 14:16and that the kids would believe
• 14:18that there were other kids and
• 14:20completing the task at the same time.
• 14:22So our primary behavioral outcome was,
• 14:25was ingratiation,
• 14:26namely how many of the peers who
• 14:28had rejected the participant.
• 14:30Did the participant nonetheless
• 14:32vote to to stay on for the next
• 14:35round through the Hawaiian Islands
• 14:37and this Island getaway task?
• 14:39And what we found was that sexual
• 14:41minority youth did in fact display more
• 14:43ingratiation than their heterosexual peers.
• 14:45And this ingratiation is a behavioral
• 14:48marker of rejection sensitivity.
• 14:50During the island getaway task,
• 14:52EG data were also recorded,
• 14:54which also allowed us to
• 14:56to collect an ERP data.
• 14:58We are particularly interested
• 14:59in an ERP that measures.
• 15:00Individual differences in neural
• 15:03reactivity to rewarding stimuli as
• 15:05opposed to to neutral or punishing
• 15:08stimuli to study sexual orientation
• 15:10differences in this reward positivity
• 15:13or rupee average ERP's were calculated
• 15:16across both the acceptance and
• 15:18rejection conditions after about 300
• 15:20milliseconds and after after the
• 15:21social feedback was given where it
• 15:23was maximal in the overall sample.
• 15:25The top panel shows the mean data from
• 15:27the heterosexual participants in the
• 15:29bottom panel shows the mean data from the.
• 15:31Sexual minority participants
• 15:33and the line in red indicates.
• 15:37The line and red indicates the responses
• 15:40to to neural responses to rejection
• 15:43and the line in green indicates
• 15:46ERP responses to to acceptance.
• 15:49And what you see is that there was
• 15:50a trend towards a small sexual
• 15:52orientation difference such that
• 15:54sexual minorities showed showed.
• 15:58Response positive feedback,
• 15:59which other research,
• 16:01including research using this sample,
• 16:02has shown to be predictive of of
• 16:04the development of depression.
• 16:05Importantly, this main effect was
• 16:07qualified by an interaction with parental
• 16:09support such that the sex orientation
• 16:11difference and repeat wasn't significant.
• 16:14It averaged or high levels of family support,
• 16:17but but was only significant
• 16:18low levels of family support.
• 16:20Now, unfortunately,
• 16:20as I showed earlier,
• 16:22LGBT youth are much less likely
• 16:25and consistently.
• 16:26More likely to report and poor parental
• 16:29lack of parental support in their lives,
• 16:32which which is unfortunate given given
• 16:35the known importance of parental support
• 16:37as a buffer against against depression
• 16:40and an evidence here suggests through
• 16:43mechanisms that might drive depression.
• 16:45So overall,
• 16:46the results that I just reviewed support
• 16:49the tenants of minority stress theory.
• 16:52You have structural and interpersonal forms
• 16:54of stigma being strongly associated with.
• 16:57Or mental health and you have this
• 16:59association being mediated by minority
• 17:01stress reactions like identity concealment,
• 17:03internalized stigma,
• 17:04rejection sensitivity that lead
• 17:06LGBTQ people to respectively,
• 17:09hide their true selves,
• 17:10feel ashamed and expect,
• 17:11and anxiously expect and poorly
• 17:14react to rejection.
• 17:15At the same time,
• 17:17because these reactions all
• 17:20represent cognitive, affective,
• 17:21and behavioral reactions within the person,
• 17:24these reactions at least can be affirmatively
• 17:27addressed through psychotherapy.
• 17:28Even if the broad structures,
• 17:29or even if if people's
• 17:31day-to-day interactions can't be,
• 17:33can't be easily changed,
• 17:35get until recently,
• 17:36no empirically supported mental health
• 17:38treatment had been created to address
• 17:40these reactions and and examined in
• 17:43RCT specifically for LGBTQ individuals.
• 17:45So therefore,
• 17:46over the past several years,
• 17:47our team here at Yale has been in
• 17:49the process of developing and testing
• 17:51the efficacy of an intervention
• 17:52that affirmatively responds to
• 17:54stigma and addresses minority stress
• 17:55reactions to improve mental health.
• 17:58So to create such a treatment,
• 18:00we interviewed numerous mental health
• 18:01professionals around the country,
• 18:03people who spent their entire
• 18:04careers working with LGBTQ people.
• 18:06We asked them how we should adapt CBT,
• 18:09just standard cognitive behavior
• 18:11therapy to best support LGBTQ people
• 18:15and ability to to to adaptively
• 18:18respond to minority stress.
• 18:20We also interviewed many dozen LGBTQ
• 18:23people who themselves were were
• 18:25currently experiencing depression,
• 18:27anxiety, suicidality, and substance use.
• 18:30And and and we packaged all those that
• 18:33kind of qualitative and expert input into a.
• 18:37Into a CBT treatment manual that that
• 18:40provides LGBTQ people with the tools
• 18:42to understand and challenge the ways
• 18:44that minority stress impacts their lives.
• 18:46And they're in their mental health.
• 18:48So the mental health professionals
• 18:50told us about the way they've
• 18:52seen LGBTQ people grow past the
• 18:54painful lessons of stigma by first
• 18:57acknowledging the existence of stigma,
• 18:58kind of raising their awareness of the
• 19:01fact that stigma is is a reality and
• 19:03that that that that has to be coped
• 19:05with in the lives of LGBTQ people.
• 19:08Learning skills for standing up
• 19:09to stigma is kind of insidious
• 19:11and harmful impact.
• 19:13But within within oneself,
• 19:15learning it how stigma can can
• 19:18shape biases like internalized internalized
• 19:22**** negativity or internalized transphobia,
• 19:24leading people to believe that they're
• 19:26inferior to heterosexual cisgender people,
• 19:29leading people to kind of chronically
• 19:31anxiously expect rejection even, you know,
• 19:33in their in their close relationships
• 19:35or even even among other LGBTQ people.
• 19:38Um, learning new empowered.
• 19:40Um, ways of of of behaving
• 19:42and finding support, meaning,
• 19:44and purpose, including from within
• 19:46the LGBTQ community as they do so.
• 19:49So like I said,
• 19:50we packaged that expertise that
• 19:52that qualitative feedback into
• 19:54into a treatment package and LGBTQ
• 19:57affirmative CBT quite simply,
• 19:59and then tested the treatment success
• 20:01and an initial randomized control trial.
• 20:03And keep in mind,
• 20:05until this research no.
• 20:06Despite the the fact that LGBT people
• 20:08are one of the highest risk groups for
• 20:10for these mental health challenges,
• 20:12no mental health treatment for
• 20:14LGBTQ people had ever been tested
• 20:16in an RCT to see if it worked so.
• 20:18Unfortunately don't have time to go
• 20:20into the the exact content of the
• 20:22treatment but I'll I'll I'll summarize
• 20:24by saying that it's guided by a
• 20:26personally tailored minority stress
• 20:28case conceptualization that specifies
• 20:31techniques for addressing various
• 20:33minority stressors that that LGBTQ
• 20:35people might be facing and then and
• 20:38and and then provides a set of of.
• 20:42The principles and techniques,
• 20:44both based in CBT and the integration
• 20:46of CBT with minority stress theory,
• 20:49that help LGBT people raise
• 20:51awareness of the existence of early
• 20:53and ongoing sources of minority.
• 20:59That help LGBTQ people reduce
• 21:01characteristic ways of avoiding the
• 21:03emotional consequences of minority stress,
• 21:06such as drinking alcohol use, self harm
• 21:09and other forms of emotional numbing,
• 21:11asserting oneself against the emotional
• 21:13consequences of minority stress to
• 21:15break social withdrawal tendencies.
• 21:17Reworking. Internalized.
• 21:21Umm, homophobic, biphobic,
• 21:23transphobic, and cultural ideologies.
• 21:26Importantly, not challenging the veracity
• 21:28of of discrimination in the world,
• 21:31but instead challenging the veracity
• 21:33of their internalization that one is
• 21:35rejectable or that one is not lovable,
• 21:37or that one is inferior to to to others.
• 21:40And then intentionally building and
• 21:42drawing on cues of of social safety and
• 21:45and and and and and people's worlds,
• 21:48including from within the LGBT
• 21:49community and the broader community.
• 21:51So this this treatment overall
• 21:54teaches people these cognitive,
• 21:56affective,
• 21:56and behavioral skills to help them
• 21:59start overcoming the the patterns
• 22:02of thinking and behaving that they.
• 22:04People often have a root and minority
• 22:07stress and often are kind of have
• 22:09a deeply planted root that that
• 22:11characterizes a lot of their a lot of
• 22:13their behavior and that sets in a lot
• 22:15of their reactions to stress that can
• 22:17set them up for mental health risk.
• 22:20So in an initial weightless control
• 22:22trial with with 60 young game asexual
• 22:24men in New York City we found initial
• 22:26evidence for the promise of this treatment.
• 22:29So looking at the lines in blue which
• 22:31is the effect of the from having.
• 22:34Received the treatment compared to the
• 22:36lines and Gray which is the effect
• 22:38from from being put on a wait list.
• 22:39We found that the treatment helps
• 22:41these young gay bisexual men feel
• 22:44less depressed less anxious,
• 22:45drink less and and have safer sex
• 22:48at three months following the the
• 22:51the treatment or the the wait list.
• 22:53We do very similar study with 60 young
• 22:57sexual minority women in New York City
• 22:59many of whom were were transgender
• 23:01or gender non binary similar to
• 23:02the pilot study with young gay and.
• 23:04Sexual men we found that compared
• 23:06to waitlists the treatment was
• 23:08associated with significantly greater
• 23:09reductions and and and depression and
• 23:12anxiety and an unhealthy alcohol use.
• 23:14All these outcomes that that are
• 23:17particularly disproportionately
• 23:19likely to affect LGBTQ people.
• 23:22We then asked whether this treatment
• 23:24might be more efficacious than
• 23:25existing treatments for LGBTQ people.
• 23:27So in a trial with 254 young gay and
• 23:30bisexual men in Miami and in New York City,
• 23:32we compared this LGBTQ affirmative
• 23:34CBT to supportive counseling in the
• 23:37community and to a single session
• 23:39of HIV testing and referral.
• 23:41That we chose HIV testing and single
• 23:43session HIV testing and and and referral
• 23:46because it's the most common way that
• 23:48young gay and bisexual men encounter
• 23:50and LGBT specific healthcare services.
• 23:52I'm in the US testing for HIV,
• 23:55that is,
• 23:56with the with the.
• 23:59In a in a in an HIV STI screening
• 24:02appointment takes,
• 24:03you know 20-30 minutes and it's
• 24:05and it's a frequently used service
• 24:06in the lives of LGBTQ people.
• 24:08But we thought we'd use that
• 24:09as a as a quite weak control.
• 24:11And what we found was that LGBTQ
• 24:13affirmative CBT was associated with
• 24:15small to moderately relative benefit
• 24:17compared to to the two other treatments.
• 24:20Effect sizes were the largest for substance
• 24:22use problems with LGBTQ affirmative CBT,
• 24:25yielding significantly greater
• 24:26impact on the substance use problems
• 24:28than the other two conditions.
• 24:30Also consistent with the trans
• 24:32diagnostic basis of the treatment,
• 24:34the targets minority stress reactions
• 24:36theorized to underlie all of the
• 24:39multiple Co occurring outcomes that
• 24:41disproportionately affect LGBTQ people.
• 24:43We also found that the treatment
• 24:45was associated with significantly
• 24:47stronger efficacy for reducing
• 24:49comorbidity across depression,
• 24:50anxiety, substance use, and HIV risk.
• 24:52Then the then the two comparison conditions.
• 24:57We then performed what's called
• 24:59a treatment effect heterogeneity
• 25:01analysis to identify the strongest
• 25:03moderator of set of moderators of
• 25:05LGBTQ affirmative CBT's efficacy.
• 25:06So we did this by asking the the,
• 25:09the the therapist over the the
• 25:11four or five years of this study.
• 25:13So we surveyed them at the end of the
• 25:15study to nominate any and all factors
• 25:17that they thought may have led some
• 25:19participants to benefit more from
• 25:20LGBTQ affirmative CBT than others.
• 25:22They suggested a list of 20 potential
• 25:24moderators that we then subjected
• 25:26to a machine.
• 25:27Learning approach to identify
• 25:29the top moderators.
• 25:31So we pre registered this analysis
• 25:33and with the primary outcome of our
• 25:35comorbidity count of depression, anxiety,
• 25:38HIV risk behavior and substance use.
• 25:41Only one moderator emerged as significant,
• 25:45namely race and ethnicity,
• 25:46such that Black and Latinx participants
• 25:49who compose the majority of the sample
• 25:51experience significantly more reduction in
• 25:53comorbid conditions from LGBTQ affirming.
• 26:00So we haven't been able to empirically
• 26:02identify the reasons for this moderation.
• 26:04But clinically, we noted that
• 26:05black and white Max participants
• 26:07seem more amenable to the minority
• 26:08stress focus of the treatment.
• 26:10Perhaps because they were they
• 26:11were better able to to draw,
• 26:12they were able to drop on the
• 26:14racial socialization experiences,
• 26:15to incorporate the minority stress
• 26:18focus of LGBTQ affirmative CPT and
• 26:21into and into into their lives,
• 26:23or perhaps perhaps because
• 26:25LGBTQ affirmative CBT.
• 26:27Addressed not only minority stress,
• 26:29sexual minority stress,
• 26:30but all identity related stress in their
• 26:33interactions and and in reality it.
• 26:35It would be hard if not impossible
• 26:37to kind of tease apart how
• 26:39people are are incorporating an
• 26:41identity focused lens of CBT.
• 26:42And separately depending on the all
• 26:44the the different social identities
• 26:46they might they might identify.
• 26:48For example the assertiveness
• 26:49practice in the treatment wouldn't be
• 26:52limited only to 1 aspect of someone's
• 26:54identity who would naturally apply
• 26:55even to racially hostile situations.
• 26:57As well.
• 26:59So we're now studying whether this
• 27:01treatment can can lend itself to to,
• 27:03to maybe even more efficient reach
• 27:05by using an asynchronous form of the
• 27:08treatment whereby LGBTQ young people,
• 27:09in this case anywhere in the US,
• 27:11can receive 1010 weeks of the
• 27:13psychoeducational content about minority
• 27:15stress and CBT and learn skills for
• 27:17addressing its emotional impact.
• 27:19They can read about this online,
• 27:20they can share their written reactions
• 27:22and try out the CBT skills through
• 27:24through homework exercises in their lives,
• 27:27and they can receive and and.
• 27:29They do receive weekly feedback
• 27:31from from the therapist this we're
• 27:33in the process of comparing this
• 27:35treatment to to to relatively weak
• 27:37control condition just simple self
• 27:39monitoring and mood and minority
• 27:41stress and then and then this will
• 27:43set us up to eventually compare this
• 27:46this perhaps more efficient way of
• 27:48delivering the treatment to to to
• 27:51perhaps the more time intensive
• 27:52standard you know kind of 50 minute
• 27:55session once a week that would and
• 27:57that we've that we've used in our other.
• 28:00This will allow us to to to weigh
• 28:02the relative benefits of this
• 28:04delivery modality capable of of
• 28:08potentially wider reach.
• 28:10So these are initial trials.
• 28:16Oh, wait, sorry. So, so Speaking of REACH
• 28:20and I now want to highlight our team's
• 28:22efforts to ensure the implementation of
• 28:25this effective treatment and our local
• 28:27communities and to ensure that our treatment
• 28:30response to the needs of those communities.
• 28:32So we know that that LGBTQ identities
• 28:35don't exist in isolation, but rather
• 28:37they Co occur with other identities.
• 28:39We also know that if current rates continue,
• 28:42a black gay man in the US has
• 28:43a one in two chance of becoming
• 28:45infected with HIV in his lifetime,
• 28:47the average Latinx.
• 28:48Scared bisexual man.
• 28:49So one in three chance of becoming infected
• 28:51with HIV in his lifetime at current rates,
• 28:54with the source of this disproportionate
• 28:56risk being solely in intersecting
• 28:58sources of structural discrimination
• 29:00towards LGBTQ people and and
• 29:02racism towards people of color.
• 29:04We also know that the fastest
• 29:06increases in new new incident cases
• 29:07of HIV are occurring among young
• 29:09black gay and bisexual men in small
• 29:12urban areas places like New Haven.
• 29:13So I was approached by by medical provider
• 29:16what one of the medical directors.
• 29:19Working at the Fairhaven Community Health
• 29:21Center and FQHC here in New Haven,
• 29:23who was witnessing this epidemic first hand.
• 29:26She reached out to me after a particularly
• 29:29hard month of of diagnosing several of her,
• 29:32her young black and white next gay
• 29:34patients with with HIV and said that,
• 29:37that that that,
• 29:39that she was,
• 29:41that she was very motivated to try
• 29:43to address the the kind of holistic
• 29:45circumstances in their lives that that set
• 29:47them up for this risk and she knew about.
• 29:49This Umm this LGBTQ affirmative
• 29:51CBT treatment that we had done and
• 29:54and asked if if we could perhaps
• 29:56deliver the treatment at Fair Haven
• 29:58do it in a group based setting.
• 30:00Because she had the the sense that
• 30:02that her patients could benefit from
• 30:04talking to each other to help them
• 30:06see that they that they weren't alone
• 30:07to help them see that they were going
• 30:10through similar struggles to build
• 30:12community and so and so we did that.
• 30:14And, and doctor Skyler Jackson,
• 30:16who was at the time of postdoc in my lab,
• 30:18now Sistant professor in our department.
• 30:21He he he he he brought the study.
• 30:23He was also one of the the therapist
• 30:25on the study.
• 30:26And then before we deliver the treatment,
• 30:28we interviewed about a dozen game
• 30:30bisexual men of color in New Haven to
• 30:32get a sense of their interlocking forms
• 30:34of stigma and how they influence their
• 30:36mental health, their day-to-day lives,
• 30:38and their sense of community and connection.
• 30:40We then packaged the results of
• 30:42those interviews into the LGBT.
• 30:44Affirmative CBT treatment to make sure
• 30:46that the therapist can be prepared
• 30:49and responsive to the to the unique.
• 30:51Challenges and and resiliencies
• 30:53experienced by by, by this community.
• 30:59For the treatment and this pilot study
• 31:01to to 21 black and Latino gay and
• 31:03bisexual men that they are having.
• 31:05I should say that Doctor Jackson has
• 31:07since received a K award to expand
• 31:09this work to to to similar communities.
• 31:11It's it's similar similar locales
• 31:13like in bisexual men living there
• 31:16in the in the US S so in this small
• 31:18pilot that we did a fair haven we
• 31:20found reductions in the expected
• 31:21direction for for almost all of the
• 31:23outcomes and perhaps most relevant for
• 31:25this pilot study we found evidence.
• 31:27That this intersectionality adapted group
• 31:29based format of LGBTQ affirmative CBT
• 31:32could be implemented quite feasibly.
• 31:34Most of the participants showed up
• 31:36to to to nearly all of the sessions,
• 31:39but perhaps looking at how they
• 31:41talked about the treatment in their
• 31:43own words kind of drives the the,
• 31:45the, the, the,
• 31:45the point and the purpose of this
• 31:48intervention home quite well,
• 31:49for example.
• 31:52One participant said I used to think
• 31:53that being gay was a bad thing and
• 31:55that I should be ashamed of myself,
• 31:56that I should try and be straight
• 31:57and that I shouldn't hang out
• 31:59with like other gay people.
• 32:00Now, after the treatment,
• 32:02it's it's the exact opposite, another said.
• 32:04After the study.
• 32:05I came out to my mom,
• 32:06I came out to a lot more friends.
• 32:07Now I'm just like,
• 32:08I'm just living my best life,
• 32:09as people say,
• 32:10going back to that kind of the the the
• 32:12cost of of hiding a part of oneself,
• 32:15including from from one's own parents,
• 32:17and kind of the the the challenges,
• 32:19but also potential benefits.
• 32:21Of coming out,
• 32:22which this treatment helped
• 32:23this this one young man do,
• 32:25another participant said.
• 32:26It helped me a lot to how do I say it?
• 32:27Be happy with myself like except myself.
• 32:29In the session,
• 32:30people actually listened and
• 32:31cared about what I had to say,
• 32:33so the treatment helps
• 32:34strengthen their identities,
• 32:35as gained bisexual men most consistently,
• 32:39most participants noted a simple but
• 32:41impactful take away illustrated by
• 32:43this this last participants quote
• 32:45simply that the treatment made
• 32:47them feel like they weren't alone,
• 32:49which is something that.
• 32:50That the providers working at Fairhaven
• 32:52had been seeing in their patients.
• 32:54They had the sense of isolation,
• 32:56the sense of loneliness,
• 32:57and the treatment was was
• 32:59actually a self against that.
• 33:00So with the goal of assessing whether
• 33:03LGBTQ affirmative CBT can continue
• 33:05to be implemented and compete in
• 33:07community settings across the country,
• 33:09we identified an ideal network of
• 33:11settings where this can happen.
• 33:12So.
• 33:13You know,
• 33:14the US doesn't have a universal
• 33:17healthcare system.
• 33:18But but it does.
• 33:19But it does have kind of this amazing
• 33:21resource that was created by the LGBTQ
• 33:24community in the in the 1950s and 60s.
• 33:26Specifically,
• 33:27the US has more than 300
• 33:30LGBTQ community clinics.
• 33:31These are these are grassroots
• 33:33clinics established and in
• 33:34many cases and during the gay
• 33:36rights movement of the 60s
• 33:38where LGBTQ people were were were not having
• 33:41their their needs their their healthcare,
• 33:43mental health care needs met.
• 33:45So they they they did it themselves.
• 33:47These centers got even more attention
• 33:49during the the the AIDS epidemic in
• 33:51the 80s and 90s in particular where
• 33:53where where they became a kind of an
• 33:55indispensable place to to to do the
• 33:57outreach and provide the care that they
• 33:59continue to be neglected by more formal.
• 34:01Settings. About 40% of these of
• 34:05these clinics provide mental
• 34:07health services to to a combined.
• 34:10The report is it's a combined 50,000 people,
• 34:13LGBT people each year.
• 34:14Because they often provide free or heavily
• 34:17subsidized mental health services,
• 34:19they're providing these services to people
• 34:21who otherwise wouldn't be able to get care.
• 34:22I'm including individuals with lower
• 34:24incomes and LGBT people of color,
• 34:26trans women.
• 34:27So we specifically partnered with Centrelink,
• 34:29which is the coordinating hub of
• 34:31the US's 300 plus LGBTQ centers,
• 34:34to survey the directors and CEO's
• 34:36of these centers to get a sense
• 34:38of their capacity and interest
• 34:39and willingness to implement.
• 34:41Our LGBTQ affirmative CBT
• 34:43intervention and as you can see.
• 34:46Most.
• 34:46Of the CEO's and directors reported
• 34:50that they saw room to improve their
• 34:52their current mental health offerings.
• 34:54Most also reported that their staff can
• 34:56benefit and being trained in an evidence
• 34:59based treatment like LGBTQ affirmative CBT.
• 35:01And 100% of them said that they'd be
• 35:03willing to provide the administrative
• 35:05support and staff time necessary
• 35:06for their mental health staff to be
• 35:09trained and an LGBTQ affirmative CBT.
• 35:11So we train them,
• 35:13but not only that,
• 35:14we use implementation science to determine
• 35:15whether the training was efficacious.
• 35:17Namely we used a weightless control
• 35:19trial over 11 week training and
• 35:22LGBTQ affirmative CBT to to about
• 35:24130 providers in this initial pilot
• 35:26test working in LGBTQ community
• 35:28centers across 21 states.
• 35:30This was this,
• 35:31this took place during the pandemic
• 35:33when we were all everyone in my lab
• 35:35was kind of sitting at home with
• 35:37kind of wondering what to do and
• 35:38how to do it and and and this was
• 35:40kind of an ideal opportunity to take
• 35:42advantage of the ability to train
• 35:44people remotely to do work that they
• 35:46that they were continuing to do.
• 35:47And and and and we're kind of in in
• 35:50in great need of support for doing
• 35:52it given the increasing demands
• 35:54including among LGBT people for from.
• 36:00So we we we organized like a lunchtime
• 36:04webinar, training live every week for
• 36:0611 weeks and randomly assigned half of
• 36:08the providers to the to to receive the
• 36:11training immediately the other half.
• 36:13So wait list where they received
• 36:14the training after four months.
• 36:16And what we see looking at the lines in blue,
• 36:17which is the effect of receiving the
• 36:19training compared to the lines in red,
• 36:20which is the effect of receiving
• 36:22the wait list.
• 36:22Our analysis showed that the training
• 36:24was associated with significantly
• 36:26greater increases in LGBTQ affirmative.
• 36:28Cultural competence,
• 36:29minority knowledge of minority,
• 36:31stress theory and how it can
• 36:33be applied in practice.
• 36:34CBT knowledge and familiarity with
• 36:36the LGBTQ affirmative CBT skills.
• 36:39And then we took this cool thing where
• 36:42we hired young LGBTQ actors in in
• 36:45Hollywood to role play being LGBTQ client.
• 36:48We gave them kind of a script of
• 36:49how to role play being kind of a
• 36:52characteristic young LGBT person
• 36:53going through a hard time.
• 36:54We then showed that video to each
• 36:56of the providers individually
• 36:57and then had the providers.
• 36:59Describe how, what,
• 37:01what tools,
• 37:02what skills and approaches they
• 37:03would use just in free form
• 37:05writing to help that person.
• 37:06And then we had research
• 37:08assistants code the writing for
• 37:11the presence of LGBTQ affirmative
• 37:13CBT content and and and this last.
• 37:15Kind of box of skills used shows that
• 37:18that the providers are much more
• 37:21likely to describe applying LGBTQ
• 37:23affirmative CBT to the to the to
• 37:25the role played client from before
• 37:27the training compared to after the
• 37:29training and the coders were masked
• 37:31to whether the the description came
• 37:33from the control group the the
• 37:35active training condition or whether
• 37:37they were submitted at baseline
• 37:39or or following the training.
• 37:41So finally,
• 37:42we wanted to know whether this we
• 37:44wouldn't know whether the streaming can
• 37:46be disseminated to other high need,
• 37:48high stigma locales.
• 37:51So first,
• 37:52we're working with our colleagues
• 37:53in Changsha,
• 37:54China and Hunan province to adapt
• 37:57LGBTQ affirmative and CBT to respond
• 37:59to the intersections of Chinese
• 38:01culture and LGBTQ identities there.
• 38:03Given that the the experience of of
• 38:06LGBTQ people can look quite different
• 38:08than than than LGBT people in settings.
• 38:11Like the US with them with with with
• 38:14kind of marriages of convenience
• 38:16being highly highly common something
• 38:19like 70% of young LGBT people
• 38:21report being and I'm and I'm in a
• 38:23heterosexual marriage where both
• 38:25partners know we're both parties
• 38:26know that I'm that that one or both
• 38:28of the others or themselves LGBT
• 38:30and and and this is done you know
• 38:33to uphold a kind of Chinese family
• 38:36values and and and and and other
• 38:39pressures that young LGBT people in China.
• 38:41Will report related to their to
• 38:43their sexual identity.
• 38:45And so we used,
• 38:46I should say they used the the team
• 38:48in China has really done a fantastic
• 38:49job carefully adapting the treatment model,
• 38:52working with the LGBTQ community to
• 38:54ensure that the resulting treatment
• 38:56was appropriate and resonant with them,
• 38:58the young LGBT people that they work with.
• 39:01This included meeting with experts
• 39:04community demonstrations training
• 39:06the therapist and doing a initially
• 39:08a small open trial which showed
• 39:10you know early promise of the of
• 39:12of the ability of the session to
• 39:15impact depression and and anxiety.
• 39:17We're not testing this adaptive treatment
• 39:19using our asynchronous delivery
• 39:21platform that I showed earlier and
• 39:23in RCT with them with with with 120
• 39:25young gay and bisexual men and and and
• 39:28working with colleagues in China has.
• 39:31Has been rewarding because of
• 39:34connections to like the China CDC and
• 39:37the the the interest in in government
• 39:40officials and and and and and kind of.
• 39:42And in addressing the the spread
• 39:45of HIV among getting bisexual men
• 39:47and doing that through through.
• 39:49They're delivering tailored healthcare so.
• 39:52So we have buy in of of of not only
• 39:54community partners but also on government
• 39:56and and and and healthcare officials
• 39:58who who can who can work to to uptake
• 40:01and and implement this intervention if
• 40:03it continues to show to show promise.
• 40:06Another side of our work is Romania and
• 40:08which is one of the most normatively
• 40:10anti LGBTQ countries in Europe where
• 40:12identity concealment is the norm
• 40:14where and where LGBTQ affirmative
• 40:16mental health services are are are
• 40:18pretty much whacking completely.
• 40:20So in addition, you know,
• 40:21we had received funding to do these RCT's
• 40:24of mostly of HIV prevention interventions
• 40:26with young gay bisexual men in Romania.
• 40:29But at the same time we
• 40:31were hearing all these,
• 40:32you know,
• 40:33very moving and compelling stories
• 40:35about how these men existed in in
• 40:38in a situation where they couldn't
• 40:40receive any other mental or sexual
• 40:43health support outside of our study.
• 40:45So, you know,
• 40:46it raises this kind of quandary
• 40:48of here delivering individually.
• 40:50Focus things like CBT to to
• 40:53population what you're sending them.
• 40:56You know, but you know.
• 41:00Doctors that that can't that can't
• 41:02be supportive outside of the
• 41:04context of that of that study.
• 41:06So what we do is we started building a
• 41:08cadre of of of mental health professionals
• 41:11who could who could work to to kind
• 41:13of change the attitudes of the mental
• 41:16health professionals in Romania to
• 41:17to to be more LGBTQ affirmative.
• 41:20So one of the things we did for
• 41:22example was invite a kind of a network
• 41:24of of mental health professionals
• 41:26in remaining to to attend.
• 41:28The training that we did of
• 41:31LGBTQ affirmative therapy and.
• 41:34200 people showed up and then we
• 41:36randomized them to either received the
• 41:37training in person or to receive it remotely.
• 41:39And this is an important.
• 41:42Implication from kind of global
• 41:45implementation perspective and that you know,
• 41:48it's hard and and challenging to to
• 41:50show up in person to every country
• 41:52where such a training might be needed.
• 41:54But if we can show that remote online
• 41:56training works works just as well,
• 41:58it really has implications for feasibility
• 42:00and cost and time effectiveness
• 42:02and in fact that's what we found.
• 42:04So the lines here whether people
• 42:06were the providers were either
• 42:08randomized to receive the training
• 42:09in person or to receive it online.
• 42:12Regardless of whether providers
• 42:13received it in person or online,
• 42:15we found that we found significant
• 42:17reductions in explicit bias and even
• 42:2015 months after the the treatment
• 42:22and reductions in in implicit bias
• 42:25towards LGBT people and uptake
• 42:27in LGBTQ affirmative practice.
• 42:28Skills, beliefs,
• 42:29behaviors and the effect sizes here are
• 42:32very small because they're comparing the,
• 42:35the, the, the, the,
• 42:36the impact of delivering of delivering the
• 42:39treatment in person versus versus online,
• 42:41so, so.
• 42:42Some kind of important test of
• 42:44preparing for future implementation.
• 42:46So, so future research directions,
• 42:49I think,
• 42:50involve continuing to be curious and
• 42:52open about whether and how we need
• 42:55to adapt existing treatments for for
• 42:57sexual and gender minority populations.
• 42:59While at the same time I may be
• 43:02moving beyond RCT's to speed up
• 43:03the dissemination of treatments
• 43:04that we already have,
• 43:05including so we have we we have
• 43:08many evidence based psychotherapies.
• 43:11For example, for for the general population,
• 43:15those therapies can be adapted right
• 43:17now using using kind of evidence based.
• 43:22LGBTQ tailored case conceptualizations
• 43:24and so like we've derived this type
• 43:27of guidance and published it of how
• 43:29people who were delivering whether it's
• 43:31IP T or or more expensive experiential
• 43:34or emotion focused therapies or more
• 43:37more interpersonally focused therapies
• 43:39can can can all borrow from the the
• 43:42general quite general LGBTQ affirmative
• 43:44principles that that that we use to
• 43:47adapt and CBT to to think creatively and
• 43:49carefully about how to make existing.
• 43:52Evidence based practice more responsive
• 43:54to to the LGBTQ population without
• 43:56going through the you know 1015 years
• 43:59of of effort needed to develop the
• 44:01treatments from scratch to adapt them
• 44:02test them in RCT's and then I'm and
• 44:04then ultimately hope that they'll be,
• 44:06that they'll be implemented.
• 44:08I'm Speaking of implementation.
• 44:10What our what our lab is currently
• 44:12working on is using the tools of
• 44:14implementation science including from
• 44:15global mental health context where
• 44:17where you know evidence based practice
• 44:19is being scaled up using tech and
• 44:21task shifting to ensure that providers
• 44:23are trained in treatments that are
• 44:25responsive to the needs of of local
• 44:27communities especially in in high need
• 44:29settings across the US and and globally.
• 44:32So a lot of excitement about about
• 44:34about moving this work forward to
• 44:36to to reach those who who could
• 44:39continue to benefit from it.
• 44:41So in conclusion,
• 44:42you know from the beginning of the LGBTQ
• 44:44rights movement and affirmative stance
• 44:46towards mental health was you know,
• 44:49one of the few basic demands
• 44:51of the LGBTQ community.
• 44:53We have to keep in mind that you know,
• 44:54the, the, the, the,
• 44:56the mental health profession,
• 44:57you know,
• 44:58it's historic role in the mental
• 45:00health of LGBTQ people was to use
• 45:03its power to pathologize LGBTQ people
• 45:05through through pathologizing,
• 45:07diagnosis,
• 45:07abusive conversion therapies and
• 45:09things that justified the.
• 45:11The criminalization and kind of and
• 45:14kind of you know spending ones life you
• 45:17know as a as a persecuted population
• 45:20you know spent in solitude and sickness.
• 45:24But the fields come a long way
• 45:25and I think we can,
• 45:26we,
• 45:26we can and should be proud of that and
• 45:29we now have scientific evidence that
• 45:31LGBTQ affirmative CBT's are efficacious.
• 45:33They're capable of community
• 45:35implementation and they're capable
• 45:36of relatively efficient dissemination
• 45:38to high to high stigma settings
• 45:40worldwide and where that.
• 45:41Without legacy and and all too
• 45:44often unfortunately persist in our
• 45:46continued application of research
• 45:47to the to this express need of
• 45:50the LGBTQ population and will only
• 45:53hopefully continue to ensure its
• 45:54continued and equity and and thriving.
• 46:01All of you for showing up.
• 46:02Thank you to the Department of Psychiatry
• 46:04for being one of my professional one of
• 46:07my two professional homes here at Yale.
• 46:09Thank you for the support of of
• 46:11this topic and through the LGBTQ and
• 46:13advocacy and practice and research
• 46:14efforts and Department of Psychiatry
• 46:16the research presented here today is
• 46:18there is the result of the hard work
• 46:20of of the committed caring people
• 46:21shown here and and and and and several
• 46:24others who who've who've been part
• 46:25of our initiative and in the past.
• 46:28Most of whom are listed here as long as,
• 46:31as well as the funding sources
• 46:32and our collaborators.
• 46:33So thank you all and I eagerly
• 46:35look forward to your questions.
• 46:37Thank you.