Toward Cognitive-Behavioral Therapy for Sexual Minority Women: Voices From Stakeholders and Community Members

Abstract

Sexual minority women (SMW) experience an elevated risk of mental health problems compared to heterosexual women. However, knowledge gaps remain regarding whether cognitive-behavioral therapy (CBT) interventions meet SMW’s mental health needs. Further, virtually no studies have integrated stakeholder (i.e., researchers with content expertise in SMW’s health and clinical providers who work with SMW) and community member (i.e., SMW) perspectives to identify CBT approaches that address SMW-specific issues. This study used qualitative data gathered from 39 SMW who reported depression, anxiety, suicidality, and heavy drinking in the past 3 months and 16 content experts and clinical providers to obtain information relevant to enhancing CBT for SMW. In addition, we used thematic analysis to identify themes related to the adaptation and delivery of CBT for SMW. Building on prior literature, this study’s findings revealed seven considerations for delivering mental health services to SMW: (1) attending to SMW’s diverse gender identities and expressions; (2) focusing on SMW’s nonbinary stressors; (3) formulating SMW’s gender-based stressors within a feminist framework; (4) applying intersectionality frameworks; (5) incorporating issues of diversity, multiculturalism, and social justice; (6) addressing the role of trauma exposure; and (7) addressing the role of alcohol use in SMW’s lives. These considerations are reviewed in terms of their implications for clinical practice, with a focus on enhancing applications of existing CBT interventions, to best respond to the unique needs of this population.

Sexual minority women (SMW) face a greater risk of mental health and substance use problems, including depression, anxiety, posttraumatic stress disorder (PTSD), and alcohol use disorders, compared to heterosexual women (Evans-Polce & McCabe, 2020; Hughes et al., 2020; Roberts et al., 2010). According to minority stress theory (Meyer, 2003), these disparities are rooted in SMW’s disproportionate exposure to stigma. Repeated stigma exposure produces elevations in general maladaptive stress responses among SMW relative to heterosexual women, including rumination, social isolation, and emotion dysregulation (Hatzenbuehler, 2009). Stigma also leads to minority stress responses, including identity concealment, expectations of rejection, and negative self-schemas (Hatzenbuehler, 2009; Meyer, 2003; Pachankis, Mahon, et al., 2020). These general and minority stress responses serve as pathways through which stigma operates to compromise this population’s mental health (Dyar & London, 2018; Fitzpatrick et al., 2020). These stress pathways also represent modifiable treatment targets in cognitive-behavioral therapy (CBT) interventions (Pachankis, McConocha, et al., 2020; Pan et al., 2021).

SMW’s gender identities (e.g., cisgender, gender fluid) and presentations (e.g., appearance, gender roles) often transcend traditional, cisheteronormative gender roles (Halberstam, 2012; Levitt et al., 2012; Scheer et al., 2021). Several studies have demonstrated that mental and behavioral health risks associated with societal stress (e.g., heterosexism, sexism, cissexism) differ for SMW based on their sexual and gender identities. For instance, one recent study found that sexism was significantly associated with more psychological distress for SMW who report high masculine gender presentation but not those who report low masculine gender presentation (Scheer et al., 2021). Given that some SMW identify their gender as gender diverse (e.g., nonbinary; Dworkin et al., 2018; Page et al., 2021; Riggle et al., 2018; Tabaac et al., 2019), within the present study, SMW refers to individuals who: (a) self-identify as women or may have experienced stigma based on their identity as women, regardless of their sex assigned at birth or gender identity; and (b) identify their sexuality as something other than heterosexual. Including transgender and nonbinary individuals who identify as SMW is consistent with literature focused on SMW (Fitzpatrick et al., 2020; Levitt et al., 2012; Page et al., 2021).

Despite the well-documented sexual-identity-related mental health disparities affecting women, as well as SMW’s unique risk factors for poor mental health, significant knowledge gaps remain regarding evidence-based practices for addressing SMW’s transdiagnostic mental health needs (Huang et al., 2020). A recent systematic review (Layland et al., 2020) revealed that of 37 interventions that addressed stigma experienced by sexual minorities, only 2 were designed or adapted for SMW (Logie et al., 2015; Whitton et al., 2017), and neither explicitly focused on SMW’s mental health. In a review of 46 minority stress-focused interventions (Chaudoir et al., 2017), one intervention—an expressive writing treatment—was designed for SMW (Lewis et al., 2005). More recently, a scoping review of 71 substance use interventions (Kidd et al., 2021) noted the lack of tailored interventions for SMW. It is unclear whether targeted interventions, compared to traditional interventions, more effectively promote SMW’s mental health (Beard et al., 2017). Nonetheless, SMW, particularly those with multiple marginalized identities, report greater treatment dissatisfaction and more unmet treatment needs compared to heterosexual women (Allen & Mowbray, 2016; Jeong et al., 2016; McCabe et al., 2013).

The Promise of Cognitive-Behavioral Therapy for SMW

CBT interventions adapted from transdiagnostic treatments, such as the Unified Protocol (Barlow et al., 2011), are well-positioned to address SMW’s comorbid health issues for several reasons (Pachankis, 2018; Pachankis, McConocha, et al., 2020). For example, CBT is cost-effective, accessible, and efficacious (Rector et al., 2014) and thus could reduce SMW’s notable barriers to treatment utilization and satisfaction (McCabe et al., 2013; Scheer et al., in press). In addition, several CBT tenets overlap with multicultural counseling principles, including an emphasis on empowerment, attention to client strengths and support systems, and affirmation of clients’ marginalized identities (Steele, 2020), which may be particularly impactful for SMW.

Several studies have demonstrated preliminary support for adapting CBT interventions for sexual minority men to respond to sexual minority stress (Pachankis et al., 2021; Pan et al., 2021) and sexual and gender minority youth (Austin et al., 2018; Craig & Austin, 2016). For example, in two of the only randomized controlled trials of adapted CBT interventions for sexual and gender minority populations, adapted CBT was associated with stronger reductions than waitlist in depression, alcohol use, and condomless anal sex among sexual minority young adult men (Pachankis et al., 2015), and with stronger reductions across mental, behavioral, and sexual health outcomes and their comorbidity compared to LGBTQ-affirmative community treatment-as-usual and HIV testing and counseling (Pachankis et al, 2021). CBT treatments have since been adapted to address intersectional stressors affecting sexual minority men of diverse racial and ethnic identities in the U.S. and other countries (Flentje, 2020; Jackson et al., 2022; Pan et al., 2021) in small open pilot studies. For instance, one recent intervention consisting of a 9-session cognitive behavioral intervention aimed to bolster sexual minority men’s ability to cope with stigma due to salient intersectional minority identities (e.g., HIV status, race/ethnicity, sexual identity; Flentje, 2020). Another intervention addressed intersectional stigma by modifying an existing 10-week, CBT intervention for gay and bisexual men (Pachankis et al., 2015) to develop a group-based CBT treatment that (1) integrated content on race-related stress into the therapist manual and session material; (2) adapted treatment elements to encompass intracommunity stress, distinct stereotypes of gay and bisexual men of color, and intersectional forms of proximal stress (e.g., identity conflict, cultural homelessness); (3) incorporated strengths and resiliencies of gay and bisexual men of color across history; and (4) ensured that therapists possessed knowledge of intersectional stigma (Jackson et al., 2022). Several open trials have also found that LGBTQ-adapted CBT is associated with reductions in depressive symptoms and improved coping skills among sexual and gender minority youth (Austin et al., 2018; Craig & Austin, 2016). The importance of attending to intersectional stressors and resiliencies is reflected in recent guidance for adapting LGBTQ-affirmative evidence-based treatments, and is supported by case studies and feedback on previous clinical trials of LGBTQ-affirmative CBT (Pachankis et al., in press).

EQuIP (Empowering Queer Identities in Psychotherapy) represents one of the few CBT interventions designed to address the minority stress source of SMW’s depression, anxiety, and alcohol use (Pachankis, McConocha, et al., 2020). EQuIP is also the only such intervention that has been tested in a randomized controlled trial (RCT) for SMW (Pachankis, McConocha, et al., 2020). EQuIP is a minority-stress-focused, 10-session CBT intervention adapted from the Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders (hereafter referred to as “Unified Protocol”; Barlow et al., 2011). Indeed, targeting SMW’s health-eroding stress mechanisms is consistent with the Unified Protocol’s overarching goal of focusing on underlying vulnerabilities rather than disorder-specific symptoms (Wilamowska et al., 2010). In a waitlist-controlled trial, EQuIP demonstrated preliminary efficacy in reducing SMW’s depression, anxiety, emotion dysregulation, and rumination compared to waitlist (Pachankis, McConocha, et al., 2020). However, effect sizes for some outcomes, such as alcohol use and suicidality, were small, and minority stress responses were not significantly affected by the intervention. These findings, combined with prior research, suggest that additional treatment targets, including SMW’s elevated rates of trauma and alcohol use, might be needed to enhance existing and future CBT interventions for SMW (Hughes et al., 2020; Pachankis, McConocha, et al., 2020).

Notably, an intervention, such as EQuIP, responds to the professional American Psychological Association (APA) guidance to address minority stress in treatment (APA, 2021). APA guidelines are specific recommendations regarding professional behavior identified for use across psychotherapy orientations to deliver culturally tailored interventions (APA, 2021). The APA notes that “Although direct causal links between proximal minority stressors and psychological processes are under continued investigation, psychologists understand that proximal minority stress and psychological processes play a joint role in the mental health, physical health, and psychosocial well-being of sexual minority persons.” Beyond assessing the impact of proximal minority stress on sexual minority populations’ health and well-being, the APA recommends that psychologists help sexual minority clients increase their awareness of proximal minority stressors while also validating their experiences (APA, 2021).

Moreover, several interventions, including expressive writing (Lewis et al., 2005), computer-based interventions (Boyle & LaBrie, 2021; Israel et al., 2021), liberation psychotherapy (Russell & Bohan, 2007), and emotion-focused couples therapy (Hardtke et al., 2010), among others, have been developed or adapted to improve the lives of sexual and gender minority people, including SMW. We recognize the value and importance of diverse psychotherapy orientations and treatment modalities such as these. At the same time, this paper focuses on enhancing applications of existing CBT interventions for SMW given recent calls for improving current CBT approaches (Naeem, 2019) and the potential for transdiagnostic CBT interventions to effectively address SMW’s co-occurring health issues (Pachankis, McConocha, et al., 2020). Details about potential treatment targets, including stressors, are discussed below.

SMW Unique Stressors Based on Multiple Oppressed Identities, Including Nonbinary Sexual and Gender Identities

Research on improving CBT for SMW with multiple marginalized identities is needed. SMW who hold multiple oppressed identities, for example, across race/ethnicity and socioeconomic status (Crenshaw, 1989), experience numerous forms of stigma and resulting health inequities (Bowleg et al., 2003). Intersectionality (Crenshaw, 1989), a theoretical framework rooted in the work of Black feminists and women of color social justice activists and scholars, posits that SMW’s identities are situated within cultural and historical contexts of systemic privilege and oppression (Bowleg et al., 2003). For example, Black SMW are exposed to a trifecta of oppression rooted in their existence and socialization as women in a sexist society, sexual minorities in a heterosexist society, and Black people in a racist society (Bowleg et al., 2003). Concurrently, sexual and gender minority people with intersecting marginalized identities, including SMW of color, often display resilient stigma-coping strategies, such as embracing positive aspects of the self, being involved in a community, and engaging in social activism (i.e., “positive intersectionality”; Ghabrial, 2017). Still, SMW who experience multiple forms of inequality face mental health risks due to their disproportionate and often compounding experiences of societal stress (Helminen et al., 2021) and oppression (Cerezo & Ramirez, 2020). However, there are virtually no empirically supported recommendations for providing CBT interventions to SMW who have experienced multiple forms of oppression to date.

As previously mentioned, some people who identify as SMW also identify their sexuality or gender as nonbinary or fluid (Fitzpatrick et al., 2020; Levitt et al., 2012; Page et al., 2021). Yet, there is a dearth of literature on CBT approaches for best responding to the specific needs of people with diverse sexual and gender identities, including nonbinary and gender diverse SMW. Individuals with nonbinary identities embody, transform, and resist hegemonic binary categorizations (Anzaldúa, 1987; Chalfin, 2021). For some SMW, perceived and enacted experiences of prejudice are related to holding a sexual or gender identity that occupies an in-between space or “borderland” (i.e., nonbinary stress; Callis, 2014). For example, SMW who identify as plurisexual (e.g., bisexual, pansexual), genderqueer, or gender nonbinary can experience negative stereotypes, both from within and outside the lesbian, gay, bisexual, transgender, and queer (LGBTQ) community, including perceptions that such nonbinary identities are unstable and illegitimate (Bradford & Catalpa, 2019). Further, nonbinary stress is associated with poor mental health (Callis, 2014). The current study aims to provide suggestions for ways to adapt CBT interventions to best meet the mental health needs of SMW who experience stressors based on their multiple oppressed identities and who experience nonbinary sexual or gender identity stressors.

SMW’s Disproportionate Risk of Trauma Exposure

Due in part to societal stigmatization against sexual minorities, SMW experience high rates of trauma. For instance, SMW are at least twice as likely to encounter childhood physical abuse, adulthood sexual assault, and intimate partner violence than heterosexual women (Roberts et al., 2010; Scheer et al., 2020). In addition, compared to trauma-exposed heterosexual women, trauma-exposed SMW face an elevated risk of depression, anxiety, and suicidality (Bing-Canar et al., 2020; Newins et al., 2021; Scheer et al., 2019). For SMW, cumulative experiences of gender-based violence, such as sexual assault and intimate partner violence, can contribute to SMW’s generalized sense of fear and excessive behavioral and emotional avoidance (Szymanski & Henrichs-beck, 2014). However, existing trauma literature largely focuses on heterosexual women despite SMW’s elevated risk of trauma-related health concerns (Hughes et al., 2014; Roberts et al., 2010; Scheer et al., 2019). Moreover, no clinical trials have evaluated CBT interventions adapted to address trauma-exposed SMW’s mental health concerns.

SMW’s Elevated Rates of Alcohol Use

Alcohol use disorders are also notably pronounced among SMW compared to heterosexual women (Hughes et al., 2020). For example, SMW are nearly four times as likely to drink to intoxication and engage in heavy episodic drinking than heterosexual women (Hughes et al., 2020). Moreover, alcohol use disorders disproportionately affect SMW across the lifespan (Hughes et al., 2020). Indeed, alcohol use may be especially heightened among SMW who have mental health concerns and who hold other marginalized identities (e.g., religious minorities, immigrants) and SMW female youth (Cerezo, 2016; Hughes et al., 2020; Scheer et al., 2019). Nevertheless, relatively little is known about how CBT interventions can address SMW’s hazardous drinking outcomes (e.g., alcohol dependence, alcohol-related problem consequences).

Present Study

Mental health providers have an ethical responsibility to deliver accessible, culturally relevant, and effective mental health services to individuals from historically oppressed backgrounds (Trimble & Fisher, 2006). For instance, mental health interventions that are culturally adapted, such as for a racial/ethnic group, can significantly improve client mental health outcomes (for a review, see Griner & Smith, 2006). Stakeholder and community involvement in intervention development and evaluation is essential to inform culturally sensitive, effective, and sustainable treatments (Trimble & Fisher, 2006). However, virtually no studies have considered stakeholders’ input (i.e., researchers with content expertise in SMW’s health and clinical providers who work with SMW) and SMW involvement to identify CBT approaches that address SMW-specific concerns. Utilizing qualitative data gathered from researchers with content expertise in SMW’s health; SMW who reported depression, recent suicidality, and heavy drinking in the past 3 months, including those who received the EQuIP intervention; and clinical providers who currently work with SMW, the current study sought to obtain information relevant to adapting existing CBT interventions, including EQuIP, for SMW. Specifically, this study aimed to identify themes relevant to the adaptation and delivery of CBT treatments for SMW based on stakeholder and SMW input. This study also offers several clinical practice recommendations for improving SMW’s mental health based on these themes.

Method

Participants and Procedures

We used qualitative data gathered from four samples during the EQuIP intervention development and evaluation process. Details about participant recruitment and data collection procedures for each sample are presented below.

Sample 1: Content Experts

Twelve psychologists with content expertise in advancing knowledge of and delivering evidence-based treatment, including CBT, to SMW completed a semistructured phone interview in December 2017. These content experts were recruited for potential participation through a systematic search of (1) scientific databases, (2) national professional membership rosters that promote evidence-based or affirmative treatment approaches for SMW, and (3) LGBTQ-specific leadership rosters of professional psychological organizations. From this systematic search, a research assistant compiled a list of 39 content experts with SMW-focused publications. Given the pilot trial of EQuIP’s focus on integrating stakeholder and community member perspectives to identify evidence-based therapy approaches that address SMW-specific issues, content experts with the highest number of clinically relevant publications focused on SMW’s mental health were contacted for an interview. In total, 18 content experts were invited by email to complete an interview and were asked whether they had direct clinical experience with SMW. Of those contacted, two indicated that they did not have prior or current direct clinical experience with SMW, two indicated they were unavailable to participate, two did not respond, and 12 completed an interview.

Content experts who expressed interest in the study were contacted to receive information about the study and were provided an online consent form. Upon receipt of electronic signature, each content expert was asked to review a one-page summary of the Unified Protocol (Barlow et al., 2011) before the interview (see Appendix A). We provided content experts with core elements of each module (e.g., principles and techniques) rather than the therapist or client manual (Barlow et al., 2011) to reduce participant burden while simultaneously communicating the Unified Protocol’s fundamental principles and techniques. This approach is consistent with intervention research adapting CBT approaches to treat various populations (Castro-Camacho et al., 2019), including sexual minority men (Pachankis, 2014).

Semistructured interviews were audio-recorded, transcribed, and checked for accuracy by the research staff. Participants received $100.00. Eleven participants identified as cisgender women, and 1 participant identified as a cisgender man. Other demographic information (e.g., sexual orientation, race/ethnicity) was not collected.

Three clinical psychology doctoral students conducted these interviews. Interviews lasted 65 minutes on average (range = 37–85). They contained several questions assessing content experts’ understanding of SMW’s experiences and health consequences of minority stressors and about their own clinical experiences working with SMW. Additionally, during the interview, content experts were asked to review a one-page summary of the Unified Protocol (Barlow et al., 2011) and describe strategies to adapt this intervention for SMW who report experiencing minority stress, depression, anxiety, and alcohol use problems. All content experts received the same one-page summary of the Unified Protocol (Barlow et al., 2011).

Sample 2: SMW Community Members

Nineteen SMW community members (who did not receive the EQuIP treatment) completed a semistructured, in-person interview between August 2017 and December 2017. The third author conducted all interviews with SMW community members in a private interview room in New York City (NYC). Interviews lasted 53 minutes on average (range = 32–96) and contained questions assessing participants’ experiences of depression, anxiety, suicidality, and alcohol use problems. Additionally, during the interview, SMW community members were asked to review the same one-page summary of the Unified Protocol (Barlow et al., 2011) provided to content experts and to offer input for how this intervention could be tailored or adapted to better help SMW cope with minority stressors, particularly those who report depression, anxiety, alcohol use problems, and suicidality.

Eligibility criteria included being between 18 and 35 years of age; identifying as a SMW (e.g., lesbian, bisexual, pansexual, queer) with the option to select multiple gender identities; currently living in NYC; and reporting English fluency, past-3-month depression symptoms (i.e., ≥ 2.5 on the 2-item Brief Symptom Inventory [BSI] screen; Lang et al., 2009), recent suicidality (i.e., ≥ 1 on the Suicidal Ideation Attributes Scale; Spijker et al., 2014), and to be inclusive while still recruiting SMW at some risk, at least one instance of past-3-month heavy drinking (≥ 4 drinks in one sitting; U.S. Department of Health and Human Services, 2015). In addition, given that lifelong health behaviors and coping strategies are evident in young adulthood (Fergusson et al., 2015) and that knowledge of developmentally appropriate intervention targets could enhance the prevention of mental health problems over the lifespan (Ames et al., 2018), we focused on recruiting SMW community members who were young adults.

SMW community members were recruited in-person at SMW community venues and events (e.g., NYC Pride) and online (e.g., Facebook) and through advertisements and flyers posted in community centers and LGBTQ-friendly businesses. In total, 771 SMW community members completed the online screening survey, 601 of these individuals provided their contact information and consent to be contacted for further screening, and 126 met the eligibility requirements for further screening. Of these 126 individuals who were contacted, 45 completed a phone screening survey conducted by the third author for past-3-month suicidal ideation, and 21 met all eligibility requirements. Two eligible participants did not attend their scheduled interviews and did not respond to follow-up attempts to reschedule (see Appendix B).

Regardless of their eligibility status, all participants were provided a resource list containing information for accessing local and national mental health and violence-related resources (e.g., The Trevor Project, The Anti-Violence Project, and the National Suicide Prevention Hotline). Before completing the interviews, SMW community members completed a demographic questionnaire, measures of minority stress, and a suicide risk assessment. Following each interview, participants completed this same risk assessment to identify whether crisis services were needed. No participants endorsed suicidality or needing crisis services following these interviews. Semi-structured interviews were audio-recorded, transcribed, and checked for accuracy by trained research staff. Each participant received $50.00.

Participants’ mean age was 26.00 (SD = 3.21). Eighteen participants’ sex assigned at birth was female (95.0%), and 1 participant’s sex assigned at birth was male (5.3%). Six participants (31.6%) identified their sexuality as queer. Most participants identified their gender as cisgender (n = 14; 73.7%). More than half of the participants identified as racial or ethnic minorities (52.6%).

Sample 3: EQuIP Providers

Three mental health providers who delivered EQuIP and one clinical supervisor of EQuIP participated in one focus group in August 2019. This focus group included questions about EQuIP’s acceptability and suggestions for further adapting this LGBTQ-affirmative CBT intervention for SMW. This focus group lasted approximately 70 minutes and was conducted by the fifth author, a licensed clinical psychologist and study principal investigator, in a private interview room in NYC. This focus group was audio-recorded, transcribed, and checked for accuracy by trained research staff.

Of the participants in the focus group, one EQuIP provider was a counseling psychologist, two were advanced clinical psychology doctoral students, and one was a licensed clinical psychologist. We collected demographic information (e.g., age, sexual orientation, gender identity, sex assigned at birth, race/ethnicity) among EQuIP providers, including those who participated in the focus group, along with providers who delivered ESTEEM (Effective Skills to Empower Effective Men), a CBT intervention adapted for gay and bisexual men (Pachankis et al., 2015). Demographic information was aggregated across providers and thus was not available specifically for EQuIP providers who participated in the focus group. All therapists received training in psychology from APA-accredited psychology doctoral programs in New York and reported various primary theoretical orientations. Of note, the first author of the present study served as one of the EQuIP clinical supervisors. No authors were EQuIP providers.

Sample 4: EQuIP Participants

Twenty randomly selected SMW who had received the EQuIP intervention in a preliminary efficacy pilot study (Pachankis, McConocha, et al., 2020) were interviewed about the treatment’s acceptability and suggestions for further adapting this LGBTQ-affirmative CBT intervention for SMW.

Eligibility criteria included being between 18 and 35 years of age; identifying as a SMW (e.g., lesbian, bisexual, pansexual, queer) with the option to select multiple gender identities; currently living in NYC; and reporting English fluency, past-3-month depression or anxiety symptoms (i.e., ≥ 2.5 on either the depression or anxiety scale of the 4-item BSI screen; Lang et al., 2009), and at least one instance of past-3-month heavy drinking (≥ 4 drinks in one sitting; U.S. Department of Health and Human Services, 2015). As noted previously and elsewhere (Pachankis, McConocha, et al., 2020), EQuIP was focused on young adult SMW given the need to intervene on stress-related mechanisms during this developmental period.

EQuIP participants were contacted at their 6-month follow-up assessment to participate in one 45-to-60-minute, semistructured exit interview by phone between August 2019 and October 2019. Three trained research assistants conducted interviews with EQuIP participants. Semistructured interviews were audio-recorded, transcribed, and checked for accuracy by trained research staff. Each participant received $40.00. In total, 25 EQuIP participants were contacted to participate in a phone interview. Of these individuals, 4 did not respond to outreach attempts to schedule an interview. Twenty-one interviews were completed. One interview was not included in the analysis, given that the audio recording was inaudible.

EQuIP participants completed an average of 9.15 sessions (range = 1 to 10; SD = 5.83) out of 10. EQuIP participants’ mean age was 25.80 (SD = 11.96). All participants’ sex assigned at birth was female. Twelve participants (60.0%) identified their sexuality as queer. Most participants identified their gender as cisgender (n = 13; 65.0%). More than half of the participants identified as racial or ethnic minorities (60.0%).

Table 1 contains each sample’s demographic characteristics. The host university’s IRB approved study methodology. Notably, content experts and clinical providers earned $100 to fairly compensate them for their time (i.e., in a way that approximates an hourly rate for a mental health provider). In contrast, we paid community members at a rate that would not likely introduce financial coercion to participate.

Table 1.

Demographic Characteristics Across Four Qualitative Data Sources (N = 55)

	Sample 1. Content experts (n = 12)	Sample 2. SMW community members (n = 19)	Sample 3. EQuIP providers (n = 4)	Sample 4. EQuIP participants (n = 20)
Characteristic	n (%)	n (%)	n (%)	n (%)
Age (mean; SD)a	–	26.00 (3.21)	–	25.80 (11.96)
Sex assigned at birth
Female	11 (91.7)	18 (94.7)	1 (25.0)	20 (100.0)
Male	1 (8.3)	1 (5.3)	3 (75.0)	0 (0.0)
Gender identity
Cisgender woman	11 (91.7)	14 (73.7)	1 (25.0)	13 (65.0)
Cisgender man	1 (8.3)	0 (0.0)	3 (75.0)	0 (0.0)
TGNCNB	0 (0.0)	5 (26.3)	0 (0.0)	7 (35.0)
Sexual identityb
Lesbian	–	4 (21.1)	–	3 (15.0)
Bisexual	–	3 (15.8)	–	1 (5.0)
Pansexual	–	1 (5.3)	–	1 (5.0)
Queer	–	6 (31.6)	–	12 (60.0)
Asexual	–	0 (0.0)	–	1 (5.0)
Otherc	–	5 (26.2)	–	2 (10.0)
Race/ethnicityd
Racial/ethnic minority	–	10 (52.6)	0 (0.0)	12 (60.0)
White	–	9 (47.4)	4 (100.0)	8 (40.0)

Note. EQuIP = Empowering Queer Identities in Psychotherapy; SMW = sexual minority women; TGNCNB = transgender, gender non-conforming, or nonbinary.

^aAge was not assessed among content experts or EQuIP providers.

^bSexual identity was not assessed among content experts or EQuIP providers.

^cOther sexual identity includes SMW who identified with more than one sexual identity label, such as Demi-sexual and Asexual.

^dRace/ethnicity was not assessed among content experts.

Data Analysis

Before data analysis, all personal identifiers were redacted from transcripts. We employed a multistep thematic analysis approach to identify themes related to adapting and delivering evidence-based mental health treatments for SMW (Braun & Clarke, 2006). Consistent with qualitative research among SMW (Huxley et al., 2014), we chose thematic analysis given that it is concerned with: (1) understanding individual experiences and locating accounts within broader societal contexts, (2) providing concrete direction on deductive analysis, and (3) operating from a realist epistemology (i.e., that participants’ responses reflect reality; Braun & Clarke, 2006; Levitt et al., 2021).

The first and second authors, a licensed counseling psychologist and psychiatric epidemiologist, respectively, with formal training in qualitative methods, coded and analyzed the data. Following the initial analysis, the third author, a graduate student researcher with formal training in qualitative methods, independently validated the emerging thematic framework. Regarding positionality, research team members included insiders and outsiders (Corlett & Mavin, 2018) of the target population (i.e., diverse across gender identity, sexual identity, sex assigned at birth, and race/ethnicity). Authors’ scholarship broadly focuses on sexual and gender minority mental health. Across the research team, one member was a project coordinator, two were postdoctoral fellows, and two were faculty members. Reflexivity was achieved by collaboratively developing and modifying codes and having ongoing discussions about our cultural and personal biases and assumptions (e.g., norms around assertiveness or identity disclosure) based on our relative positions. This process might have informed sensitivity during data analysis (Braun & Clarke, 2006; Levitt et al., 2021). All analyses were conducted using Dedoose, version 8.1.8 (2018) to allow for iterative coding and refinements.

To become familiar with the four unique datasets, both coders (i.e., first and second authors) read the same two randomly selected interviews from the first three samples, and the one interview for the final sample (i.e., the focus group), eight in total. To generate initial codes, the coders employed an open coding process whereby they developed and modified codes iteratively (i.e., through frequent conversation and refinements; Braun & Clarke, 2006). After completing this first phase of data familiarization and open coding, the two coders split the remaining interviews and continued coding to develop a structured codebook including umbrella “parent codes” and more granular “child codes.” These codes were deductively derived from the raw data and guided by: (1) open-ended questions from the semi-structured interviews and focus group; (2) existing literature on SMW’s health, coping, trauma, and clinical interventions (e.g., (Drabble & Trocki, 2005; Hughes et al., 2020; Logie et al., 2015; Scheer et al., 2020, 2021; Whitton et al., 2017); and (3) the current study’s overarching objective to identify themes relevant to the adaptation and delivery of CBT approaches for SMW (Braun & Clarke, 2006). An iterative process of reading, coding, and refining parent and child codes was adopted to ensure that the developing themes were fully grounded in the data (Braun & Clarke, 2006).

After several meetings, the first and second authors reviewed and finalized the parent and child codes and defined themes. Specifically, coders reviewed emergent parent and child codes, determined and resolved coding discrepancies, collapsed redundant categories, and recoded any data that was not consistently coded. The coders met twice in person for several hours to modify the coding framework and then define overarching themes from the finalized set of emergent codes. After these two meetings, the parent and child codes and defined themes were reviewed and finalized with the fifth author, a clinical psychologist and study principal investigator with expertise in developing LGBTQ-affirmative CBT interventions.

Trustworthiness was enhanced by an independent reviewer (i.e., the third author) who compared the codebook and themes against seven randomly selected transcripts across each sample (Morrow, 2005). These randomly selected transcripts included two interviews from content experts, SMW community members, and EQuIP participants, respectively, and the focus group with EQuIP providers. This independent validation process determined that emergent codes and finalized themes accurately reflected the four sources of data, suggesting that others can make similar interpretations of the data (Hackman et al., 2020). The two coders and the third author developed a dictionary of salient quotes to demonstrate groundedness (i.e., that findings are rooted in a thorough analysis of the data; Levitt et al., 2021). Specifically, a validation sheet was created that included a description of each theme. Quotations were extracted across each data source and documented for each theme. To check the credibility of our approach and emergent themes, we presented analyses and salient quotes to 10 researchers with expertise in SMW’s health. The authors discussed and revised the codebook based on feedback received.

Results

Seven primary themes emerged regarding suggestions for adapting and delivering CBT interventions for SMW. These themes are described in detail below and summarized in Table 2. Clinical implications of the themes are discussed in the final section of the Discussion.

Table 2.

Qualitative Themes and Clinical Recommendations Derived from Content Experts, Sexual Minority Women Community Members, EQuIP Providers, and EQuIP Participants (N = 55)

Theme	Summary	Clinical Recommendations
Attend to SMW’s diverse gender identities and expressions	SMW present in gender-bending ways by adopting a range of gender signifiers Participants discussed unique gender-based stressors that SMW experience	Cognitive restructuring techniques could help SMW to locate the source of negative internalized thoughts within adverse environments rather than attributing these thoughts to personal failings Assertiveness training might help SMW to engage in shared decision making around idiographic treatment goals and to communicate their wants and needs in a values-driven manner Emotion regulation skills training could facilitate SMW clients’ tolerance of negative affect and reduce avoidance Consciousness-raising could offer SMW the opportunity to label stigmatizing events, avoid blaming themselves for their distress, and connect with other SMW Structural competency training could help providers work to change SMW’s social context by ameliorating oppressive forces through outreach, prevention, and advocacy Exposure therapy might help SMW to better tolerate the emotional sequelae of threatening encounters Motivational interviewing techniques could enhance SMW’s motivation to recognize potentially problematic drinking
Focus on nonbinary stressors across SMW’s sexual and gender identities	SMW’s sexual and gender identities resist hegemonic binary categorizations SMW and providers discussed challenges faced by SMW who inhabit borderlands
Formulate SMW’s gender-based stressors within a feminist framework	SMW and providers noted the need to promote SMW’s agency and resilience in response to sexism SMW and providers described patriarchal structures and systems representing important treatment targets
Apply an intersectionality framework when working with SMW who hold multiple marginalized identities	Experiences of heterosexism are inextricably tied to experiences of intersectional stressors SMW and providers discussed identity-related experiences among SMW with intersecting identities
Incorporate issues of diversity, multiculturalism, and social justice across individual, interpersonal, and structural levels	SMW and providers noted that therapists who reflect SMW’s diversity could reduce treatment barriers SMW discussed talking with their provider about cross-cultural therapy relationships
Address the role of trauma in SMW’s mental health	SMW and providers discussed the pervasiveness of gender-based violence facing SMW SMW’s trauma exposure can contribute to a generalized sense of fear and avoidance
Address the role of alcohol in SMW’s lives	Several SMW and providers described SMW’s unique risk factors for alcohol use, including permissive alcohol use norms in the LGBTQ community Providers noted that treatment efforts should address the function of SMW’s heavy drinking

Note. EQuIP = Empowering Queer Identities in Psychotherapy; SMW = sexual minority women.

Attend to SMW’s Diverse Gender Identities and Expressions

Several content experts, SMW participants, and providers discussed SMW’s diverse gender identities and expressions as important treatment considerations. For example, one content expert noted: “Gender identity is more complicated than the [male/female] binary, a lot of SMW date trans or nonbinary people. A lot of trans and nonbinary people identify as SMW” (Content expert #1). This quote demonstrates how the gender binary fails to encompass all SMW, including those assigned male at birth and reinforces essentialist notions of gender. This content expert went on to discuss unique stressors that SMW experience based on whether they challenge or adhere to hegemonic models of gender conformity: “For [SMW] who are androgynous or butch, there’s the baggage about gender…for [SMW] who are femme, there’s the sexism and stereotypes about what being feminine means that are equally harmful” (Content expert #1). This quote shows how SMW vary in their gender-related stressors, such as heterosexism and sexism.

Indeed, many content experts, SMW, and providers highlighted that SMW’s mental health challenges are often related to society’s commitment to a gender binary system and women’s structural mistreatment. One content expert talked about how “it doesn’t always get better for many queer and trans SMW.” This content expert went on to note that trans women who identify as SMW face ongoing and historical barriers that “are enormous,” including exposure to stigma from cisgender SMW because of the “separatism of the lesbian feminist era where there are still issues about who is a woman” (Content expert #4). This quote highlights how some, including cisgender SMW, question the authenticity and legitimacy of someone’s sexual minority status based on their sex assigned at birth and gender identity and expression.

SMW who transcend heteronormative gender-role constructions spoke about how others, including family, often “police” their gender expression and stigmatize their gender fluidity.

I am a girl [but]… I don’t feel like a girl…And my dad’s like, ‘why aren’t you wearing this? You want to be a boy?’ And it’s just like, when does it end? Like when do I get to be okay? … I like being feminine, but I also want to do things that are ascribed to the other gender…if I wear makeup, I want it to be because I want to do it. Not because I’m supposed to. …And it sucks that that’s not how the world works. …And it’s been a source of torture because it’s like, what do you do?

(SMW community member #1)

This quote demonstrates how SMW who embody conventionally feminine aesthetics by wearing makeup and intentionally “ascribe to the other gender” can be met with reductive and exclusionary narratives entrenched in the gender binary. In addition to this participant experiencing stigma for their fluid gender presentation, this quote also illustrates some SMW’s psychological distress and powerlessness in navigating gender norms.

EQuIP providers noted that SMW who challenge traditional gender norms often experience homophobic prejudice from outside the LGBTQ community: “I think, [compared to feminine-presenting SMW], they [masculine-presenting SMW] experience more negative feedback from the world as a result of presenting outside the gender binary” (EQuIP provider #1). This provider also described how masculine-presenting EQuIP participants “seemed to respond well to the sexual minority stress model [in the EQuIP treatment] … they found it easy to track how minority stress affected them.” Other providers similarly noted the value of interventions that address societal and structural heterosexism, especially for masculine-presenting SMW. Also, many EQuIP participants and providers spoke about the need for SMW’s diverse gender identities and expressions to be represented across treatment content.

Some SMW participants also discussed how femininity is devalued within the LGBTQ community. One feminine-presenting EQuIP participant described feeling a lack of belongingness to the LGBTQ community because they rejected a perceived queer aesthetic:

I don’t feel part of the [LGBTQ] community because I’m straight-passing…there is a queer aesthetic, especially in New York. And because I don’t fit that, we [therapist and participant] talked about how I felt navigating the [LGBTQ] community. So, it [therapy] made me kind of just look at it in a better way, where it’s like they can’t take my queerness away from me. It’s not a costume.

(EQuIP participant #1)

This quote highlights the ways that the LGBTQ community can invalidate femme identities and expressions. This quote also demonstrates that the LGBTQ community’s perception that all femme SMW adhere to normative or binary gender roles can be particularly challenging for femme SMW, given the perceived illegitimacy of SMW’s femme identities and presentations.

Focus on Nonbinary Stressors Across SMW’s Sexual and Gender Identities

Content experts, SMW participants, and treatment providers discussed challenges faced by many SMW who inhabit nonbinary sexual and gender identities, including that these identities: (a) exist beyond societal binaries; (b) are often expansive, complex, and fluid; (c) decenter heterosexuality; and (d) exist to be understood in-and-of-themselves rather than depending on the heterosexual/homosexual and cisgender/transgender binary, respectively.

Content experts noted that bisexual women face anti-bisexual prejudice from heterosexual and gay/lesbian individuals. One content expert described how “bisexual women experience unique stressors that lesbian women don’t face.” This content expert went on to note:

Bisexual women face stereotypes…that bisexual people are promiscuous, unfaithful, do not want or are not able to have a monogamous relationship. …Bisexual women talk about their partners pressuring them to change, how they identify, and telling them, ‘Well you’re in a relationship with me, and I’m a man, so you can’t still be bisexual’ or ‘I’m a woman so you can’t still be bisexual.

(Content expert #3)

This content expert’s quote illustrates that bisexual women can experience identity invalidation and erasure. Several content experts also noted that bisexual-specific stress can sometimes “contribute to bisexual women using alcohol to cope” and “over time, lead to suicidality.”

Similarly, challenging gender binarism (e.g., by identifying as nonbinary) can be interpreted as invalid, illegitimate, or deviant by cisgender or gender-binary transgender individuals. Also, many SMW are willing to conceal their nonbinary gender identities to avoid mistreatment. For example, one SMW community member noted:

We [SMW who identify as nonbinary] do exist, I am not an anomaly, I’m not confused, I didn’t change my mind, which gets really frustrating, um, but [identity invalidation] is like a daily thing. …the fact that I switch between “they” and “she” [pronouns] …adapting depending on the environment, depending on [whether I am] meeting strangers.

(SMW community member #2)

This quote demonstrates how this person alternates between pronouns due to safety concerns. However, managing a nonbinary gender identity by concealing can also reinforce negative stereotypes, including that nonbinary gender identities are illegitimate or unstable.

EQuIP providers noted that many SMW embody fluid gender identities and reject monosexual identities. For example, one EQuIP provider noted: “The [gender] binary is not as much of a thing for a lot of women [in EQuIP] …gender and sexuality are fluid for SMW” (EQuIP provider #3). Other EQuIP providers noted that SMW who challenge binary conceptualizations of sexual or gender often experience rejection and receive “negative feedback from the outside world as a result of [being] nonconforming” (EQuIP provider #3).

EQuIP participants who challenged normative notions of sexual identity, behavior, and attraction discussed how their experiences of minority stress are often distinct from those of other SMW. For instance, some SMW who identified as asexual or demi-sexual (i.e., someone who experiences sexual attraction after forming a strong emotional connection) suggested that parts of the EQuIP treatment content did not fully resonate with them. One participant who identifies as “on the asexual or demi-sexual spectrum” reported that session content related to homophobic discrimination, identity concealment, anticipatory stigma, and internalized stigma was “complicated [for me], maybe more so than for a queer person” (EQuIP participant #3). This participant further clarified that having open conversations about sex as someone who identifies on the asexual or demi-sexual spectrum and has “sex somewhat regularly” is an important component of delivering culturally tailored interventions to this population.

Formulate SMW’s Gender-Based Stressors Within a Feminist Framework

Many content experts, SMW, and treatment providers highlighted the need to promote SMW’s agency and resilience in response to gender-based stress, such as sexism, while dismantling patriarchal social structures and systems. To facilitate these objectives, several content experts shared that they use a feminist framework when working with SMW.

When working with [sexual minority] women, I say, ‘We’re doing two things here. We are trying to empower you to be stronger and more direct, to get more of your needs met. At the same time, we have a long-term strategy here – to dismantle hetero-patriarchal structures that keep you and other women in chains of oppression. So, I’m helping you personally, but I’m also helping you think about ways you can join with other women or organizations that also work toward social change.’

(Content expert #2)

Promoting SMW’s empowerment represents one way that this content expert suggests fostering SMW’s strength in the face of daily sexism. Content experts also mentioned the importance of supporting social change movements, including street-level activism and public acts of resistance, and encouraging SMW’s advocacy efforts to dismantle patriarchal social structures.

SMW community members spoke about their daily sexist experiences, including objectification, sexual harassment, and sexual assault. One SMW community member described their experience of “moving through the world when [I’m] being touched, grabbed, commented on, and stared at…like [I’m] always on display” (SMW community member #3). This participant further noted that, because of their femme presentation, they are often blamed for experiencing sexism: “It’s like, ‘Oh, well, try not dressing like a slut then.’…I disconnect myself in public a lot just because, if I were in my body, I [wouldn’t] be able to deal. Having a certain separateness or aloofness…it’s [my] coping mechanism.” Similarly, many SMW community members reported that they manage daily sexist events by using suppression-based coping strategies.

Content experts, SMW, and treatment providers noted the need to situate SMW’s mental health in the context of sexism. One EQuIP provider noted: “Structural misogyny and patriarchy seem particularly relevant to EQuIP participants’ experiences” (EQuIP provider #4). This provider also noted: “Issues related to [identifying as] women need to be acknowledged throughout [the EQuIP treatment] …maybe by incorporating feminist approaches.” Other EQuIP providers described the potential benefit of adopting a feminist lens when delivering mental health treatment to SMW given the pervasiveness of sexism. For example, one EQuIP provider stated: “[SMW] tend to distort parts of who they are to maintain relationships with people who have power over them…in male-dominated workforces, there’s a power imbalance” (EQuIP provider #1). Another provider noted that “bringing up assertiveness training earlier in the treatment…could help SMW be more authentic in relationships and in the workplace…or speak up if someone says something homophobic or to get a raise” (EQuIP provider #3).

EQuIP participants discussed how sexist events are often linked to heterosexism. One femme-presenting EQuIP participant described how men surveil and treat SMW’s bodies as objects and how SMW’s sexuality is often reduced to men’s consumption or pleasure:

[As] a femme-presenting person [dating] another femme-presenting person never once have I not been followed by someone or stalked, or openly harassed or fetishized…all these queer women are horribly assaulted…and this form of stigma isn’t recognized as homophobia when it deeply is…it’s the biggest issue we face.

(EQuIP participant #4)

This participant highlights the link between heterosexism and sexism that uniquely affects SMW. Many EQuIP participants similarly noted the value of talking about gender-based stressors in therapy. One EQuIP participant shared: “Talking about sexism [in therapy] …breaking down what these stressors look like…that was helpful for me because I don’t always process these stressors as stress. It just becomes normal. That was pretty valuable” (EQuIP participant #6).

Apply an Intersectionality Framework When Working With SMW Who Hold Multiple Marginalized Identities

For many SMW, experiences of heterosexism are inextricably linked to experiences of stressors related to race/ethnicity, socioeconomic status, immigration status, age, ability status, and gender identity. Several content experts, SMW, and providers discussed salient intersectional experiences, both positive and negative, among SMW who hold multiple minority statuses.

Content experts noted that SMW who hold multiple marginalized identities experience excess stress stemming from societal discrimination as well as intracommunity discrimination, such as racism from within the LGBTQ community. One content expert noted: “Ethnic minority SMW may not have the same connections to [White] SMW’s communities… they may find them to be racist” (Content expert #2). This expert also spoke about the role of intracommunity discrimination in preventing SMW of color from feeling connected to this community.

Many SMW community members discussed broader social and structural disadvantages related to holding multiple marginalized identities.

Identifying as Black, as a woman, as queer, as femme, as an immigrant…these [multiple marginalized identities] make you feel less than. …It’s not fantastic to be Black in America, it’s not fantastic to be a woman in any country. It’s not fantastic to be queer. We’re [queer-identified people] literally getting murdered in my country every day. …These identities give me a lot of anxiety, and, in the same breath, make me feel so proud because that’s who I am.

(SMW community member #2)

Several SMW participants discussed how intersectional identity-related stigma negatively impacts their wellbeing. Even so, this participant’s quote suggests that belonging to multiple marginalized communities can also foster a sense of pride and resilience.

EQuIP providers worked to affirm SMW of color’s interlocking experiences of oppression. Many also questioned whether delivering a mental health treatment primarily focused on sexual minority stress affected SMW of color’s treatment retention and engagement.

I think the reason she [EQuIP participant of color] dropped out is because it wasn’t an intersectional treatment. And she felt that because we focus so much on queer-related stress that it wasn’t quite related to her because her stress resulted from her racial, cultural identity, her triggers were about her experiences as a Black woman.

(EQuIP provider #2)

EQuIP providers suggested that discussing salient intersectional stressors in treatment, particularly in the first few sessions, might improve the applicability of a minority-stress-focused CBT intervention for SMW of color, ultimately improving their treatment retention.

Similarly, some EQuIP participants of color also noted the limitations of an intervention focused on sexual minority stress. For example, one EQuIP participant who identifies as “Black,” “first-gen,” “broke,” and “a sex worker,” noted: “The focus of the [EQuIP] study made sense for a different demographic than me.” This participant went on to note:

Queerness, for me, isn’t a struggle insomuch itself, but more so how it relates to my other identities. For instance, my family immigrating [to the US] was traumatic…I’m femme-presenting and a cis[gender] woman, and so I experience sexual harassment, so, it [treatment exercises targeting sexual minority stress] didn’t feel relevant [to me]. My struggles with being queer are heavily tied to gender, race, and being bi[sexual], being broke, or being a sex worker.

(EQuIP participant #2)

This quote demonstrates how SMW’s marginalized sexual identities often coexist alongside other oppressed identities. For this femme-presenting EQuIP participant of color, their experiences of immigrating in addition to their experiences related to their gender identity, race, and financial situation were more salient and stress-inducing than their experiences of heterosexism. This participant went on to discuss having difficulty with homework assignments that seemed to focus specifically on sexual minority stressors, “[I did] not really have anything to write about. It’s [sexual minority stress] just not really something I experience. Versus, like, being broke… [and having] interactions with cops.” Other EQuIP participants noted that “the focus [of EQuIP] was more on sexual minority [identity] as opposed to the intersection of [sexual minority identity] and race” (EQuIP participant #9) or “trans women’s [experiences]” (EQuIP participant #10).

Incorporate Issues of Diversity, Multiculturalism, and Social Justice Across Individual, Interpersonal, and Structural levels

Content experts, SMW, and providers noted that therapists who reflect the diversity of the SMW community could potentially support SMW’s treatment access, quality, and retention. Content experts noted that health clinics serving SMW should enlist providers who are “historically underrepresented in the mental health field,” including those who are: “gender diverse,” “women of color,” and “low income.” One content expert described how “having therapists and facilitators who represent a range of identities is particularly important” to facilitating “strong client-provider relationships” with diverse SMW (Content expert #5).

SMW community members also spoke about their preferences for receiving treatment from providers who are “queer,” “are part of the LGBTQ+ community,” “identify as women,” and who “share similar racial/ethnic identities.” For example, one participant noted:

All the therapists I see are always much older, straight, and White. And [with the last therapist,] we had nothing in common. She didn’t know anything about how I was raised…about what it was like to be raised in [an] Hispanic family with a father who was very patriarchal, domineering, and aggressive. She didn’t understand me. So, it’s like what could the therapist do? I got tired of jumping around from one therapist to another and just gave up and was like, all right, I’m just gonna do it myself. I’m going to fix myself… I shouldn’t have to do that, you know?

(SMW community member #1)

This quote demonstrates that SMW who hold different identities than their providers (e.g., age, sexual orientation, and race/ethnicity) may report lower treatment satisfaction due to feeling poorly understood by providers—factors that may be associated with early treatment termination and delay in help-seeking.

Others noted that providers’ lack of communication about having a “nonjudgmental and open stance” toward gender and sexually diverse SMW served as another barrier to accessing affirmative mental health care. For example, one participant noted: “All [a therapist] needs to do is not judge me if I tell you about girls or that I am LGBT” (SMW community member #5). This participant also discussed providers’ limited knowledge of gender diversity among SMW: “They [therapists] just need to understand that, as a trans woman, I experience a different set of issues, different kinds of discrimination.” Participants also recalled encounters with providers who lacked an understanding of intersecting sexual-identity- and transgender-related experiences.

Some EQuIP providers talked about power dynamics that exist when delivering services to SMW of color. One EQuIP provider noted: “As a White cisgender man therapist delivering EQuIP to a SMW of color, it felt problematic to steer them towards sexual identity matters where misogyny or racism was more salient … their experiences weren’t validated” (EQuIP provider #4). This therapist went on to describe the importance of taking a client-centered approach when delivering EQuIP (e.g., encouraging SMW to discuss experiences of intersectional stress or other salient identity-based stress alongside sexual minority stress).

Several EQuIP participants spoke about their difficulty in sharing experiences of homophobia/biphobia, racism, and sexism with “White cis[gender] men.” One participant noted:

Trying to talk to a White cis[gender] man about being a woman, being a Black woman, being a Black queer woman…just something that I felt like he couldn’t understand or relate to. Because unless you are that person, you’re not going to know how it feels to navigate the world in that body.

(EQuIP participant #1)

This participant described feeling that their provider, who identified as a White, cisgender man, could not empathize with or understand the lived experience of a Black queer woman. Several EQuIP participants of color spoke about barriers to being vulnerable with providers who identified as White, cisgender men, due to experiences of societal and structural racism and misogyny. One EQuIP participant spoke about how they openly talked with their EQuIP provider about feeling “burdened” for “having to explain a lot about growing up in a family of Black immigrants” and other relevant cultural norms (EQuIP participant #2). Another participant of color noted anticipating their White therapist’s racial biases (EQuIP participant #3). Some EQuIP participants of color felt uncomfortable discussing experiences of racism in therapy, describing this as a vulnerable experience (EQuIP participants #6 and #8).

In addition, many EQuIP participants discussed the benefit of working with an EQuIP provider who shared several demographic characteristics, such as perceived sexual or gender identity. One EQuIP participant noted: “I felt positive that my therapist was a queer woman…it made me feel more comfortable…my experiences resonate[d] more. I would rather have a therapist who’s a queer woman or bisexual.” (EQuIP participant #7). This participant appeared to develop a strong therapeutic alliance with their EQuIP provider in part because of their provider’s perceived or disclosed sexual minority status and gender identity.

Address the Role of Trauma in SMW’s Mental Health

Content experts, SMW, and treatment providers described the pervasiveness of trauma among SMW—experiences that seemed to be distinct from minority stressors.

One content expert noted how some SMW disconnect from their bodies to cope with trauma: “Sexual abuse divorce[s] SMW from their bodies and teaches them to hate their bodies, to think that their bodies are horrible and wrong, and to deny the realities of their bodies” (Content expert #2). Other content experts noted that because of SMW’s trauma exposure, many may “internalize negative beliefs,” “disconnect from bodily sensations,” and “detach from their ongoing painful experience.” Providers could consider helping SMW to safely “get in touch with and pay attention to their bodies’ signals, including sexual arousal” in the face of real and perceived threat, as mentioned by one content expert (Content expert #4).

SMW community members noted that mental health treatments for SMW should consider addressing SMW’s trauma histories (e.g., processing the memory of the trauma and its meaning). For example, one SMW community member noted: “The biggest issue I see [with the Unified Protocol], is that there isn’t a part where you’re specifically discussing trauma. When it comes to queer people, discussing trauma is important” (SMW community member #4).

EQuIP providers suggested that when working with SMW who experience posttraumatic stress symptoms, such as emotion dysregulation or dissociation, it could be helpful to support SMW in “grounding and returning to the present during mindfulness or exposure exercises.” These techniques could be especially helpful for SMW who are “easily triggered” by reminders of traumatic events. One EQuIP provider noted the potential benefit of including an emotion regulation module early in the treatment to help SMW identify and tolerate negative affect:

It would be helpful to have a session on emotion regulation before the induction. Up until the mood induction module, we’ve talked about emotion awareness and how to track minority stress. And then we’re saying, ‘think of something painful and come back to the present’…without giving them skills to regulate their emotions.

(EQuIP provider #1)

This quote illustrates how addressing emotion regulation skills earlier in the treatment might support SMW’s trauma-related coping and provide a greater ability to tolerate cognitive-behavioral skills training (e.g., emotion exposure hierarchy) in later sessions.

Several EQuIP participants recognized that short-term CBT treatments designed to address sexual minority stress do not necessarily lend themselves to focusing on processing the ways that trauma shapes SMW’s relationships or maladaptive beliefs about themselves or others. For example, one EQuIP participant noted: “You can’t address or unpack a bunch of cumulative, traumatic experiences over a long period into a 10-week CBT-type thing” (EQuIP participant #4). Nevertheless, some EQuIP providers appeared to be able to address trauma-related symptoms within a short-term treatment. One EQuIP participant noted: “We [participant and therapist] discussed how my avoidance patterns relate to my traumatic events and affected my experience of the minority stress exposure [exercise]” (EQuIP participant #5). According to this participant, their EQuIP provider was able to attend to the role of avoidance in maintaining the participant’s conditioned fear responses to trauma- and minority-stress-related stimuli.

Address the Role of Alcohol in SMW’s Lives

Content experts, several SMW, and providers described SMW’s combined risk factors for and outcomes of hazardous alcohol use, including frequent socialization in bars, permissive alcohol use norms in the LGBTQ community, and drinking to cope. One content expert described the need for tailored treatment efforts that address the function of SMW’s alcohol use (e.g., to facilitate social connection) and alcohol expectancies (e.g., to alleviate tension).

I think it is important for providers to ask SMW, ‘Why are you drinking? Are you drinking because you’re out with friends and want to have a good time? Because you’re celebrating something? Because you’re out in public and you’re not sure if you’re going to be accepted, or because if you don’t drink, you will stand out?’

(Content expert #3)

Overall, several content experts offered suggestions to help SMW identify alternative coping strategies to drinking and increase their commitment to reducing hazardous alcohol use. These strategies include helping SMW to increase their awareness of: (1) their drinking patterns and consequences; (2) the social context in which their drinking occurs; (3) their motivations for drinking, including coping with stigma; and (4) their perceptions of drinking norms.

Confirming content experts’ accounts of the sociocultural dimensions of SMW’s alcohol use, several SMW community members noted that they use alcohol to “fit in,” “[be] comfortable with sex,” to “come out,” and as a “social lubricant to relax.” One SMW community member noted: “Alcohol has helped me to feel okay talking to people, being in social spaces, and expressing myself” (SMW community member #3). This participant went on to note several drinking expectancies: “Drinking provides a space for me to be a louder, more passionate, angrier, or sadder person than I’m allowed to be.” Other SMW community members also discussed how they use alcohol to enhance emotions that might otherwise be “suppressed” or “compartmentalized” due to patriarchal gender norms that constrict women’s behavior. For example, one SMW community member noted: “Alcohol brings me out and makes me more touchy-feely… I’ll feel closer [with other SMW]” (SMW community member #5). Another SMW community member reported: “I always had [substance use] issues … because [women are] told that [we’re] crazy for [our] emotions and convictions” (SMW community member #3).

EQuIP providers noted that not all SMW participants identified alcohol use as a treatment target. While all EQuIP participants had reported at least one recent instance of heavy drinking, and thus could be at risk for engaging in hazardous drinking (Scheer et al., in press), one EQuIP provider noted: “Many participants had no interest in changing their drinking behavior” (EQuIP provider #4). This quote illustrates that affirmative treatments delivered to SMW should include idiographic goal-setting exercises that are compatible with SMW’s unique needs and values, including SMW’s levels of motivation to reduce potentially problematic drinking.

EQuIP participants described the centrality of alcohol in “LGBTQ social spaces.” Many EQuIP participants frequented alcohol-focused venues to form social networks with other SMW because “alcohol is a really intrinsic part of the LGBTQ community” (EQuIP participant #8). One EQuIP participant noted how their sense of belonging to the LGBTQ community shifted as they aged: “Being part of the [LGBTQ] community was connected to going out to clubs and partying and drinking. Because I don’t do that as much anymore, I don’t feel [as] connected to the community” (EQuIP participant #5). This participant went on to note that the EQuIP treatment increased their awareness of how their alcohol use “stemmed from the inability to regulate [my] emotions.” According to this participant, LGBTQ-affirmative CBT helped to highlight their drinking motives—specifically coping-oriented alcohol use.

Discussion

This study incorporated the voices of content experts, SMW, and clinical providers to uncover guidance for enhancing CBT interventions for SMW at disproportionate risk of mood, anxiety, and alcohol use disorders (Hughes et al., 2020; Roberts et al., 2010) and documented to have high rates of treatment-seeking (Allen & Mowbray, 2016; Cochran et al., 2017) and dissatisfaction with treatment (Allen & Mowbray, 2016; Jeong et al., 2016). Using data from four samples, each with distinct perspectives on SMW’s treatment, we identified seven treatment targets for SMW, including attending to SMW’s diverse gender identities and expressions; focusing on nonbinary stressors across SMW’s sexual and gender identities; formulating SMW’s gender-based stressors within a feminist framework; applying an intersectionality framework when working with SMW who hold multiple marginalized identities; incorporating issues of diversity, multiculturalism, and social justice across individual, interpersonal, and structural levels; addressing the role of trauma in SMW’s mental health; and addressing the role of alcohol in SMW’s lives. Below, we describe how these themes relate to and build upon prior research. We then discuss how these findings can inform the delivery of affirmative CBT interventions for SMW, including EQuIP, and the adaptation of existing CBT approaches for SMW more broadly.

The themes identified here complement and extend previous research. Prior research has documented SMW’s unique experiences of gender-based stressors (e.g., sexism, femmephobia) based on whether they challenge or adhere to hegemonic models of gender conformity (Szymanski & Henrichs-beck, 2014). Similarly, SMW community members spoke about their daily sexist experiences and feeling blamed for experiencing sexual harassment and objectification. Research has shown that sexism is a key driver of psychological distress and drug-related consequences among SMW, particularly those who identify as gender minorities or are masculine-presenting (Scheer et al., 2021). EQuIP participants noted the value of processing their experiences of gender-based stressors in therapy, whereas content experts and EQuIP providers stated the importance of promoting SMW’s agency and resilience in response to gender-based stress, consistent with existing literature (Chaudoir et al., 2017; Layland et al., 2020; Logie et al., 2015; Pachankis, 2018; Whitton et al., 2017).

Research among SMW has demonstrated the importance of taking an intersectional approach when conceptualizing the relationship between identity-based stressors and mental health (Everett et al., 2019). For example, SMW of color, including Black SMW, are expected to uphold complex gender and sexual identity scripts rooted in sexism, racism, and heterosexism (e.g., subverting the “White male gaze”; Everett et al., 2019; Page et al., 2021). We also found that SMW who hold multiple marginalized identities face mental health risks due to their experiences of societal and structural discrimination (Bradford & Catalpa, 2019; Callis, 2014; Cerezo & Ramirez, 2020; Everett et al., 2019; Levitt et al., 2012) as well as intracommunity discrimination (Pachankis, Clark, et al., 2020). For example, a femme-presenting EQuIP participant of color described how their experiences of immigrating in addition to their experiences related to their gender identity, race, and financial situation were stress-inducing. Conversely, and supported by prior studies (Everett et al., 2019; Page et al., 2021), SMW community members who belong to multiple marginalized communities described often feeling pride (i.e., “positive intersectionality”; Ghabrial, 2017). Examining SMW’s access to resources and resilience factors as well as risks represents a key step toward developing a comprehensive understanding of mental health among SMW with multiple minority identities (Ghabrial, 2017).

Similar to prior literature (Helminen et al., 2021; Hughes et al., 2014; Roberts et al., 2010; Scheer et al., 2020), in this study SMW and their providers described SMW’s heightened risk of trauma exposure and heavy alcohol use. For instance, SMW community members noted that “when it comes to queer people, discussing trauma is important,” while content experts and EQuIP providers spoke to the perspective of treating trauma-exposed SMW by discussing the value of using grounding exercises to support SMW’s trauma-related coping. Our findings add to the growing body of literature documenting that SMW’s cumulative adverse experiences can contribute to this population’s generalized sense of fear and behavioral and emotional avoidance (Szymanski & Henrichs-beck, 2014). Additionally, consistent research suggests that compared to heterosexual women, SMW are more likely to engage in hazardous alcohol use (Hughes et al., 2020). Our findings build on this research by documenting unique sociocultural dimensions of SMW’s drinking, including SMW using alcohol to enhance positive and negative emotions that might be inaccessible due to constricting heteropatriarchal gender norms.

Clinical Implications

Below, we offer seven considerations for adapting existing CBT approaches when working with SMW that are directly drawn from the voices of content experts, SMW, and treatment providers in this study. These considerations are in line with the core theoretical techniques and principles that appear across various CBT-based treatment approaches and are organized in terms of the following: (1) encouraging cognitive restructuring; (2) promoting empowerment; (3) improving emotion-related coping skills; (4) fostering consciousness-raising; (5) ameliorating oppressive forces through outreach, prevention, and advocacy; (6) focusing on interoceptive and situational exposure; and (7) enhancing motivation for reducing alcohol use (see Table 2). Several clinical recommendations for adapting and delivering CBT interventions for SMW are related to more than one of the seven primary themes described above.

First, this study’s findings suggest that cognitive restructuring techniques (e.g., generating alternative interpretations; Beck, 1993) could be used to help SMW locate their negative thoughts and beliefs in the context of social and structural oppression, particularly for those experiencing gender-based stressors. For example, our results highlight the importance of helping SMW clients to question the accuracy and utility of their negative thoughts or beliefs (e.g., blaming themselves for experiencing sexual assault, feeling a lack of self-efficacy in recognizing high-risk situations that might lead to heavy drinking) rather than to assume that these thoughts or beliefs are dysfunctional (Craig & Austin, 2016). Providers should avoid questioning the validity of SMW’s stigma- or trauma-related fears due to the possibility that this could signal an assumption that SMW’s thoughts, beliefs, and experiences are irrational or unfounded (Graham-LoPresti et al., 2017). As stated by this study’s participants, and consistent with research among sexual and gender minority populations more broadly (Livingston et al., 2020), validating SMW’s adverse experiences while also helping to externalize their associated negative internalized thoughts and beliefs (e.g., shame, guilt, self-blame) could help to improve this population’s ability to cope with past and future stressors.

Second, our results highlight how providers can promote SMW’s empowerment to help SMW, particularly those with nonbinary sexual and gender identities, develop adaptive and values-driven responses to future stressors. For example, providers could engage SMW in assertiveness training by encouraging SMW to take part in shared decision-making around treatment goals (e.g., reducing alcohol consumption, disclosing gender pronouns) and identify power imbalances at work and in relationships. Providers could engage SMW in role-playing activities to practice directly communicating their wants and needs in a values-driven manner, such as wearing makeup or speaking out against sexual assault. Yet, assertiveness training can conflict with some individuals’ cultural beliefs (e.g., respecting family values; Beck, 1993). Some SMW of color might face backlash for violating gender norms or other safety considerations related to openly communicating their wants and needs (Page et al., 2021; Pan et al., 2021). Yet, consistent with prior research with sexual minorities (Mereish & Poteat, 2015), our findings suggest that SMW’s denial of their needs (e.g., not paying attention to their bodies’ signals) can interfere with living authentically, leading to feelings of shame and self-blame.

Third, and consistent with what EQuIP providers noted in the present study, improving SMW’s emotion-related coping skills (e.g., emotion regulation, distress tolerance; Fitzpatrick et al., 2020; Hatzenbuehler, 2009) could be addressed early in treatment. This approach would help to (1) promote SMW’s agency and resilience in response to sexism; (2) facilitate SMW client’s tolerance of negative affect; (3) improve their confidence in accepting their emotions as valid, particularly those stemming from stigma- and trauma-related stress; (4) help SMW to engage in goal-directed behavior; and (5) potentially reduce avoidance during exposure-based exercises (Ehring & Quack, 2010; Scheer, Edwards, et al., 2021). Emotion-related coping skills training (e.g., improving attention shifting) might also help SMW who report mental health problems to mindfully observe affect, sensations, and thoughts without resorting to maladaptive coping behaviors, such as hazardous alcohol use (Ellard et al., 2010). For trauma-exposed SMW who may struggle with tolerating strong trauma-related emotions, such as shame, therapists might use grounding exercises and titration, such as helping SMW remain at the edge of what they can tolerate without becoming flooded or dissociating (Kelly & Garland, 2016).

Aligned with the fourth theme of applying an intersectional framework when working with SMW who hold multiple marginalized identities, this study’s findings suggest that raising SMW’s consciousness of multiple structural inequities could offer SMW the opportunity to consider the mental health impact of intersecting societal forces. Content experts in this study highlighted the potential benefit of encouraging SMW to locate their negative identity-related experiences within the context of interlocking systems of oppression (e.g., heterosexism, racism, sexism), to take action against oppression, and to foster a connection to communities that share their experiences. Consistent with feminist therapy techniques (Brown, 2018), providers could encourage SMW to engage in consciousness-raising by helping SMW to recognize and label stigmatizing events, avoid blaming themselves for their distress, and connect with other SMW around similar struggles (Szymanski & Henrichs-beck, 2014). As noted in this study, providers who encourage SMW to evaluate the impact of oppressive institutions might prevent SMW’s engagement in suppression-based coping (e.g., dissociation; Johnson et al., 2021).

Our fifth clinical recommendation directly maps onto our fifth theme of incorporating issues of diversity, multiculturalism, and social justice across individual, interpersonal, and structural levels when delivering CBT interventions for SMW. Specifically, our findings highlight the need for providers to work toward changing SMW’s social context by ameliorating oppressive forces through outreach, prevention, and advocacy. As noted by content experts and EQuIP providers in this study, and consistent with existing research (Ali & Sichel, 2014; Page et al., 2021), providers could consider expanding their professional roles to better understand how structural influences affect SMW’s mental health, barriers to utilizing services, coping strategies, and self-esteem. Moreover, providers should continue to actively develop their structural competency, or the demonstrated capacity to recognize the mutually reinforcing sociopolitical, economic, and structural influences on health and clinical interactions (Metzl & Hansen, 2014). Consistent with existing literature (Drustrup, 2020; Pierson et al., 2021), our findings suggest the importance of White providers acknowledging the harmful effects of systemic racism, reducing racial inequities through improving community engagement, and matching therapeutic tools to SMW’s needs, particularly when delivering identity-affirmative CBT interventions. The current study finds support for the possibility that CBT therapists who reflect the diversity of the SMW community across various identities and experiences could enhance diverse SMW’s mental health treatment access, quality, and retention. As such, clinical settings and training programs should consider increasing their racial/ethnic diversity by recruiting and retaining SMW of color.

Sixth, in an effort to address the role of trauma in SMW’s mental health, CBT providers could also consider utilizing exposure therapy techniques (e.g., creating avoidance hierarchies; Foa et al., 2005) with SMW. Indeed, exposure exercises can help SMW to gain confidence in pursuing safe and empowering experiences to cope with threats (Williams et al., 2014). Focusing on interoceptive and situational exposure could reduce SMW’s negative self-evaluations (e.g., self-blame, low self-esteem) and extinguish conditioned fear responses, such as avoidance of thinking about stressful experiences (Foa et al., 2005). Further, providers could engage SMW in exposure exercises to better tolerate the emotional sequelae of threatening encounters (Williams et al., 2014). In doing so, clinicians could help SMW cultivate coping self-efficacy (e.g., self-affirmations, mastery) to mitigate the burden of past traumas and facilitate resilience and adaptive coping in the face of threat (Cohen & Sherman, 2014; Scheer, Edwards, et al., 2021).

Notably, providers should consider SMW’s safety when designing exposure exercises, especially for SMW who face ongoing threats of violence (Kelly & Garland, 2016). For instance, individuals who have a history of sexual assault and who experience revictimization are more likely to report anxiety and avoidance symptoms compared to those who do not experience revictimization (Schock et al., 2016). Given that clients may report initial distress during an exposure exercise, providers should assess whether this increased symptomatology is related to exposure therapy or experiences of recurring abuse. Additionally, trauma-exposed individuals with PTSD symptoms may be insensitive to the context in which fear-arousing triggers occur, resulting in difficulty distinguishing safe from dangerous or risky contexts (Yehuda & LeDoux, 2007). Thus, providers working with SMW who experience active abuse should implement safety protocols to mitigate the risk of threat when conducting exposure exercises that occur out of the clinician’s office or clinic (Garfinkel et al., 2014; Olatunji et al., 2015).

Seventh, for SMW who engage in recent heavy drinking, facilitating their recognition of potentially problematic drinking and enhancing their motivation to reduce alcohol use could be achieved through motivational interviewing techniques (Miller & Rollnick, 2012), as also employed in early modules of the Unified Protocol (Barlow et al., 2011) and EQuIP (Pachankis, McConocha, et al., 2020). For example, consistent with content experts’ perspectives in the present study, providers delivering identity-affirmative CBT to SMW might assess for hazardous drinking and introduce goal-setting exercises that are compatible with SMW’s values (e.g., regarding their desire to reduce drinking levels) without countering SMW’s arguments against this change. Our findings also indicate that providers delivering LGBTQ-affirmative CBT approaches to SMW could help SMW to increase their awareness of the discrepancy between their behavior (e.g., drinking to cope) and their goals (e.g., being present) by exploring the pros and cons of SMW’s recent heavy drinking. Providers could also explore SMW’s ideas about sociocultural influences on their drinking patterns given the adverse health effects associated with heavy drinking, including the risk of alcohol use disorders (Kuntsche et al., 2017). Aligned with our seventh theme, providers might also help SMW who engage in hazardous alcohol use to better understand the form and function of their drinking, including attending to how alcohol might serve as an emotion-driven behavior and to SMW-specific drinking norms.

Limitations and Future Directions

Findings from this study should be considered in light of several limitations. First, the nature of the samples, including that all SMW participants reported specific current health challenges (e.g., recent depression, anxiety, heavy drinking), were aged 18–35, and were NYC-based, could limit the generalizability of these findings to the broader SMW population. For instance, it remains unknown whether these clinical recommendations apply to SMW who seek alcohol treatment without co-occurring mental health symptoms or for older SMW populations. Moreover, our alcohol use eligibility criterion (i.e., reporting at least one instance of ≥ 4 drinks in one sitting; U.S. Department of Health and Human Services, 2015) might not have yielded SMW participants for whom reducing hazardous drinking served as a treatment target, compared to SMW currently engaging in hazardous drinking and who are motivated to reduce drinking.

Second, while our sample of SMW was racially/ethnically diverse, there was less racial/ethnic diversity among EQuIP providers, including those who were interviewed. Further, most EQuIP providers who were interviewed identified as cisgender men. This incongruence between EQuIP participants’ and providers’ racial/ethnic and gender identities makes it difficult to discern the extent to which interviewed EQuIP participants’ responses reflected potential power dynamics with EQuIP therapists or the CBT treatment itself. This is important to assess in future studies as provider characteristics have been linked to clients’ treatment satisfaction, completion rates, and outcomes (Lindhiem et al., 2014).

Third, the study principal investigator conducted the focus group with EQuIP providers as the final session of the weekly group supervision that he provided across the study’s duration. While we applied current standards for the design, review, and reporting of qualitative research (Levitt et al., 2021), we acknowledge that potential power dynamics may have influenced EQuIP providers’ data. Specifically, EQuIP providers may have felt reticent to share their perspectives about EQuIP’s acceptability and suggestions for further adapting this LGBTQ-affirmative CBT intervention for SMW. At the same time, given the variation in EQuIP providers’ responses and identities, it is possible that a focus group, compared to individual interviews, may have facilitated EQuIP providers’ authenticity in their responses. Results should be considered in light of limits to generalizability beyond the specific sociocultural positions of the study investigators and providers and settings in which this study took place. We hope that by recognizing how our perspectives might have influenced the analytic process, as described in the data analysis section, this transparency strengthens the fidelity of our findings and the groundedness of our interpretations (Levitt et al., 2021).

Fourth, we did not have ready access to content experts’ and EQuIP providers’ demographic characteristics (e.g., sexual orientation, age), theoretical orientations (e.g., CBT vs. psychodynamic), or prior exposure to the Unified Protocol. Together, this information would help to increase the generalizability of the study’s findings.

Fifth, as with all qualitative research, while we established consensus regarding the coding of each interview, thematic findings might have differed with another team of coders with divergent identities, experiences, training, and beliefs. Although the central aims of this study were to (a) identify themes relevant to the adaptation and delivery of CBT treatments for SMW based on stakeholder and SMW input and (b) offer clinical practice recommendations for improving SMW’s mental health based on these themes, future studies should investigate SMW’s experiences receiving, and treatment providers’ experiences delivering, other SMW-specific interventions, such as normative feedback (Boyle & LaBrie, 2021).

Sixth, we asked content experts and SMW community members to review the same one-page summary containing the Unified Protocol’s (Barlow et al., 2011) fundamental principles and techniques. While an alternative approach might have involved providing participants with the therapist or client manual, we believe that this would have created undue participant burden. We instead chose an approach that is consistent with previous research that has adapted CBT approaches to treat diverse populations (Castro-Camacho et al., 2019; Pachankis, 2014). Participants’ knowledge of and experience delivering the Unified Protocol might have influenced the breadth and depth of their recommendations. For example, those who were relatively unfamiliar with the Unified Protocol may not have provided as many detailed or nuanced suggestions for adapting this specific intervention for SMW. In addition, some participants may have relied on research findings, other intervention approaches, or lived experiences to communicate general suggestions for providing interventions to SMW who report experiencing minority stress, depression, anxiety, and alcohol use problems. Further, some who were unfamiliar with the Unified Protocol may not have been aware of recent evidence demonstrating the Unified Protocol’s efficacy in treating trauma- and alcohol-related concerns (Farchione et al., 2021; Gallagher, 2017). For example, recent research has shown that the Unified Protocol is effective in targeting neuroticism among trauma-exposed individuals and mechanisms underlying excessive alcohol consumption, including alcohol cues and emotion regulation (Farchione et al., 2021; Gallagher, 2017).

Future intervention research should expand these findings by conducting an RCT of a modified version of EQuIP or another CBT intervention incorporating these uncovered recommendations. Studies could also examine whether age and geographic variability among SMW might influence treatment targets—findings that could inform existing and future CBT interventions. Also, future studies could consider incorporating positive coping, resilience, and pride as treatment targets among SMW who report multiple marginalized identities (Ghabrial, 2017; Graham-LoPresti et al., 2017). Additional studies might examine whether treatment targets should differ for SMW based on their reasons for help-seeking or presenting concerns.

Our findings also underscore the need for the development of alcohol-focused CBT interventions that target SMW’s unique risk factors for hazardous drinking, including socialization in bars, permissive alcohol use norms in the LGBTQ community, and drinking to cope, as well as the function of SMW’s alcohol use (e.g., to facilitate social connection) and drinking expectancies (e.g., to alleviate tension). Future process research might consider whether peripheral or core adaptations have a greater impact in improving SMW’s mental health needs (Chu & Leino, 2017). Other studies might build on our findings by testing the effectiveness of CBT delivery strategies that address multiple components (e.g., trauma, SMW-specific minority stressors, race-based stressors) simultaneously, sequentially, or both, to determine enhanced interventions for SMW (Broder-Fingert et al., 2019; Everett et al., 2019). Finally, future studies might examine the efficacy of CBT for SMW based on the order of skills presented (e.g., cognitive restructuring, providing psychoeducation) and time spent on each module based on SMW clients’ presenting mental health concerns (Cassiello-Robbins et al., 2020).

Conclusion

Multisector stakeholders from the current study suggest that existing CBT approaches warrant expansion to address the diverse mental health needs of SMW, including those who hold multiple marginalized identities, who identify their sexual or gender identity as nonbinary, who are trauma-exposed, and who may engage in hazardous alcohol use. Based on our findings across several samples, CBT providers’ ability to address SMW’s mental health needs could be strengthened by: (1) attending to SMW’s diverse gender identities and expressions; (2) focusing on SMW’s nonbinary stressors; (3) formulating SMW’s gender-based stressors within a feminist framework; (4) applying intersectionality frameworks; (5) incorporating issues of diversity, multiculturalism, and social justice across individual, interpersonal, and structural levels; (6) addressing the role of trauma in SMW’s mental health; and (7) addressing the role of alcohol in SMW’s lives. Taken together, the voices of content experts, SMW community members and clients, and treatment providers described in this study provide clear directions for adapting CBT for this sizable yet often underrecognized segment of the treatment-seeking population.

Highlights.

• Best practices for addressing sexual minority women’s (SMW’s) needs remain unknown.

• This study integrates stakeholder and community member (i.e., SMW) perspectives.

• This study’s findings highlight SMW’s distinct mental health treatment needs.

• This study offers suggestions for adapting existing CBT interventions to meet SMW’s needs.

• CBT approaches to improve SMW’s health need to be validated in rigorous clinical trials.

Appendix A:

Review of Program

Session 1: Building Motivation and Setting Goals for Therapy

• Not wanting to change is natural because our behavior, even problematic behavior, has worked in some ways

• Identify pros and cons of doing this program

• Develop specific goals for this program

Session 2: Learning about and Tracking Your Emotions

• Develop a greater awareness of the important role that emotions play in everyday life

• Start tracking your emotional experiences and triggers

• Understand the ways that emotions influence ongoing and future behaviors

Session 3: Becoming Aware of Your Emotions

• Learn how to observe your emotion in an objective, nonjudgmental way

• Develop skills to help you observe emotional experiences within the present moment

Session 4: Becoming Aware of Thoughts

• Learn to identify maladaptive automatic thoughts

• Learn to evaluate these thoughts objectively

• Learn more flexible ways of thinking

Session 5: Learning How Emotions Drive Behaviors

• Identify ways that you avoid certain stressful experiences

• Learn how avoiding stressful situations can lead to anxiety and depression

• Learn how your emotions drive your behavior

• Learn how to stop letting your emotions control your behavior

Session 6: Becoming Aware of and Tolerating Physical Sensations

• Learn about the role that bodily sensations play in your behavior

• Identify internal bodily sensations associated with your emotions

• Engage in exercises designed to help you become more aware of physical sensations and increase tolerance of these sensations

Session 7: Learning to Tolerate Negative Emotions

• In order to learn new ways of responding to stressful situations, it is necessary to conduct exercises to intentionally bring on this types of stress

• Gradually confront situations or thoughts or bodily sensations that may produce strong or intense emotional reactions

• Repeatedly practice confronting strong emotions through exercises in therapy and between sessions

Session 8: Maintaining Progress

• Review skills for coping with emotions

• Evaluate progress and areas for improvement

• Set short-term and long-term goals for continuing your progress

Appendix B:

Flowchart of Screening Process for Sexual Minority Women Community Members