Why do LGBTQ+ people experience the highest rates of mental health challenges, and how can therapy help address these disparities, rather than ignore or worsen them? At a recent Grand Rounds hosted by the Eidos LGBTQ+ Health Initiative, Dr. John Pachankis, Professor of Public Health, Psychiatry, and Psychology at Yale, unpacked decades of research and clinical work dedicated to answering that question. With over 200 publications and a co-authored handbook on LGBTQ+ mental health practice, Pachankis is transforming how providers respond to stigma and stress in therapy settings.
The Roots of LGBTQ+ Mental Health Disparities
LGBTQ+ individuals remain among the highest-risk populations for mental health issues, including depression, anxiety, substance use, and suicidality. A 2025 review of 46 meta-analyses identified LGBTQ+ identity as the single strongest predictor of suicide attempt across all studied populations. Yet current evidence suggests that these disparities aren’t rooted in biology, but rather are a result of exposure to stigma across the lifespan. Pachankis draws on Minority Stress Theory, which outlines two key types of stigma:
- Structural stigma: Anti-LGBTQ+ laws, policies, and public attitudes that limit rights, visibility, or safety
- Interpersonal stigma: Experiences of rejection from peers, families, employers, and institutions
Together, these forms of stress lead to internal psychological responses, like chronic concealment, hypervigilance, shame, and self-silencing, that significantly raise the risk for depression, anxiety, and unhealthy coping.
Newer data reveal just how early these disparities start. Dr. Pachankis shared research from a longitudinal study following youth from preschool through early adulthood, in which LGBTQ+ participants reported higher levels of depression as early as age 12, often linked to family rejection and peer bullying. Even more striking, neurological data show that LGBTQ+ youth have a somewhat blunted brain response to acceptance, a known risk factor for depression. That effect disappears, however, when youth report strong family support—pointing to just how protective affirming environments can be.
LGBTQ-Affirmative CBT
Until recently, no clinical trials tested treatments specifically tailored to LGBTQ+ people’s mental health. Pachankis and his team set out to change that, developing an intervention rooted in cognitive behavioral therapy (CBT) but adapted to the lived realities of LGBTQ+ people. Known as LGBTQ-affirmative CBT, the therapy doesn’t ask clients to “reframe” stigma as if it were an illusion. Instead, it acknowledges stigma’s real and persistent effects, then gives clients tools to respond with clarity, agency, and self-compassion.
This approach is detailed in the co-authored manual, LGBTQ-affirmative Cognitive-Behavioral Therapy, by Drs. Pachankis, Harkness, Jackson, and Safren.
In clinical trials across New York, Miami, and even internationally in China, LGBTQ-affirmative CBT outperformed control conditions like waitlist, community treatment, and HIV counseling in reducing comorbid outcomes like:
- Depression and anxiety
- Alcohol and substance use
- HIV-risk behavior
Notably, the therapy seems to show the strongest benefits for Black and Latino participants, suggesting its culturally responsive design resonates with intersectionally marginalized clients. It also seems to be particularly effective in high-stigma settings, where clients might have fewer community supports.
Scaling Impact
Pachankis saw the potential power of LGBTQ-affirmative CBT and wanted to make it accessible. Through a partnership with CenterLink, the national network of over 400 LGBTQ+ community centers, his team is training providers across the country on how to deliver affirmative CBT.
Through online and in-person training modules, therapy roleplay videos with LGBTQ+ actors, and supervision tools to maintain high-quality delivery, this partnership helps equip community providers with the tools to deliver effective, affirming care.
In one pilot program at a community clinic, LGBTQ-affirmative CBT was delivered in a group format to foster connection. One participant reflected:
“I used to think being gay was a bad thing, something I should be ashamed of. Now it’s like the exact opposite.”
Others described coming out to their families for the first time—or simply feeling, for once, that they were understood and not alone.
Dr. Pachankis’s work makes clear that LGBTQ+ mental health is not just a matter of individual resilience; it’s deeply shaped by social environments. Through the ongoing work of researchers like Pachankis, we are getting closer to a future where all LGBTQ+ people have access to therapy that not only understands them but affirms their lived experiences and creates pathways to healing.