Inclusion of sexual‐ and gender‐minoritized individuals in randomized clinical trials of first‐line treatments for posttraumatic stress disorder: A systematic literature review

Abstract

Clinical treatment guidelines consistently recommend cognitive processing therapy (CPT), prolonged exposure (PE), and eye movement desensitization and reprocessing (EMDR) for posttraumatic stress disorder (PTSD). The efficacy of these interventions among sexual‐ and/or gender‐minoritized (SGM) individuals has not been thoroughly investigated within randomized clinical trials (RCTs), despite known elevations in exposure to potentially traumatic events and PTSD symptoms relative to cisgender heterosexual individuals. We conducted a systematic literature review to examine the frequency with which SGM adults were enrolled in RCTs of CPT, PE, and EMDR and investigate these interventions’ efficacy in reducing PTSD symptoms among SGM adults. We searched eight databases to identify RCTs published before August 7, 2025. The inclusion criteria were: written in English; RCT investigating the impact of CPT, PE, or EMDR on PTSD symptoms; utilized a standardized PTSD measure; reported PTSD outcome data; and enrolled individuals who were at least 18 years old. Literature reviews, case studies, protocols, and non–peer reviewed articles were excluded. Our search returned 1,821 unique records, with 519 meeting all eligibility criteria. Ten records reported sexual orientation and gender identity (SOGI) information and enrolled at least one SGM individual. Among studies that reported SOGI information, 12.1% and 2.2% of participants identified as sexual‐ and gender‐minoritized, respectively. Results highlight that SOGI information is underreported in PTSD treatment research, posing significant challenges in determining the relative efficacy of these treatments and the extent to which SGM‐affirmative adaptations are necessary. We offer recommendations for clinicians and researchers, including consistent reporting of full SOGI data.

A growing body of evidence suggests that sexual‐ and/or gender‐minoritized (SGM) individuals represent an at‐risk group for the development of mental health disorders, including posttraumatic stress disorder (PTSD), relative to cisgender heterosexual (CH) individuals (Bolton & Sareen, 2011; Lu et al., 2025; Marchi et al., 2023; Rodriguez‐Seijas, Eaton, & Pachankis, 2019). SGM individuals are approximately 1.36–4.51 times more likely than CH individuals to meet the diagnostic criteria for PTSD in community and clinical samples, with approximately 7.1% of sexual‐minoritized (SM) individuals and 11.9% of gender‐minoritized (GM) individuals receiving a diagnosis of PTSD in their lifetime according to national studies of electronic medical records (Lu et al., 2025; Marchi et al., 2023; Roberts et al., 2010). Discrepant rates have been found within veteran populations as well, with Shipherd et al. (2021) finding that veterans with minoritized sexual orientations were 2.35 times more likely to have PTSD than heterosexual veterans and Livingston et al. (2022) demonstrating that the prevalence of PTSD may be 1.5–1.8 times higher among transgender veterans compared to cisgender veterans. One of the primary reasons for this discrepancy may be that, relative to CH individuals, SGM individuals are more likely to experience potentially traumatic events throughout their lifetime (Beckman et al., 2018; Livingston et al., 2020; Roberts et al., 2010; Shipherd et al., 2011). Rates of potentially traumatic interpersonal violence (e.g., unwanted sex, domestic violence, attacks, kidnapping, stalking, mugging) appear to be the most discrepant between SGM and CH individuals (Ray et al., 2021; Roberts et al., 2010).

Another important reason for this discrepancy in PTSD rates may be that SGM individuals experience stressors related to their SGM identity (i.e., minority stressors), such as violence, harassment, threats, social rejection, internalized heteronormative beliefs, or discriminatory government policies (Hoy‐Ellis, 2023; Pachankis et al., 2021; Raifman et al., 2017; Roberts et al., 2010). Even when these minority stressors do not meet Criterion A for PTSD, as outlined in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM‐5; American Psychiatric Association, 2013), they may still exacerbate posttraumatic stress symptoms (Hatzenbuehler, 2009; Meyer, 2003; Rodriguez‐Seijas, Burton, & Pachankis, 2019). For example, exposure to minority stressors may predict PTSD severity even after controlling for exposure to Criterion A events (Rodriguez‐Seijas, Burton, & Pachankis, 2019; Szymanski & Balsam, 2011). The combination of these stressors disproportionately pejorates the mental and physical health of SGM individuals beyond their isolated effects and may additionally alter SGM individuals’ self‐concept (Alessi & Martin, 2017).

Inclusion of SGM individuals in treatment research

Randomized controlled clinical trials (RCTs) of mental health interventions consistently fail to report participant sexual orientation and gender identity (SOGI) information. Previous systematic literature reviews of depression, anxiety, and substance use RCTs have observed that 0.4%–3.8% of studies examined reported SOGI information beyond binary sex or gender (Flentje et al., 2015; Heck et al., 2017; Pachankis & Safren, 2019). In a systematic literature review of PTSD RCTs published since 2020, Madnick and Spokas (2022) found that only one included study (0.5%) reported participant sexual orientation. The authors did not identify that study. The authors also observed a significant underreporting of minoritized racial and ethnic identities, as well as immigrant status.

Given that so few RCTs for PTSD report SGM‐relevant demographic information, it is difficult to determine if this population is being numerically underrepresented relative to their prevalence in the general population. In a 2024 Gallup poll, 9.3% of U.S. adults identified as lesbian, gay, bisexual, transgender, or queer (LGBTQ+), with 8.8% identifying as SM and 1.0% as transgender (Jones, 2025). Given the elevated rates of identity‐related and universal stressors, SGM individuals may comprise an even larger share of the population seeking treatment for PTSD. In clinical settings, SGM individuals appear to be significantly more likely to seek treatment for anxiety, mood, and PTSD symptoms than CH individuals (odds ratios [ORs] = 1.52–6.0; Bränström & Pachankis, 2020; Harper et al., 2025; Roxo et al., 2025), but it is unclear if this trend extends to treatment studies.

One of the consequences of this underreporting is uncertainty regarding whether evidence‐based treatments for PTSD are differentially efficacious for SGM and CH individuals. To our knowledge, there is no theoretical basis to expect that evidence‐based PTSD treatments would be harmful or particularly ineffective among SGM individuals. Indeed, several case studies have documented the successful implementation of cognitive processing therapy (CPT; Resick et al., 2024), prolonged exposure (PE; Foa et al., 2019), and eye movement desensitization and reprocessing (EMDR; Shapiro, 2017) among SGM individuals (e.g., Balcom, 2000; Kaysen et al., 2005; Ragsdale et al., 2023; Stickley et al., 2023), and cognitive behavioral therapy (CBT)–based techniques are generally effective in addressing minority stressors (Burton et al., 2019; Rodriguez‐Seijas, Burton, & Pachankis, 2019).

Treatment guidelines

Clinical treatment guidelines recognize CPT, PE, and EMDR as among the most effective interventions for reducing PTSD symptoms in adults (American Psychological Association, 2017, 2025; Bisson et al., 2019; Phelps et al., 2022; U.S. Department of Veterans Affairs & Department of Defense, 2023). Historically, these treatments have been some of the most‐researched, widely implemented, and commonly recommended trauma‐focused manualized treatments. Recent treatment guidelines, clinician‐oriented handbooks, and systematic reviews have explicitly called for the increased inclusion of minoritized individuals in studies of these interventions, alongside improved reporting of those identities, to determine the extent to which PTSD treatment outcomes may differ between SGM and CH individuals (e.g., American Psychological Association, 2017, 2025; Livingston et al., 2020; Madnick & Spokas, 2022; Pachankis & Safren, 2019; Phelps et al., 2022).

American Psychological Association (2021) treatment guidelines also broadly recommend providing affirmative psychotherapy when working with SGM individuals. The extent to which evidence‐based PTSD treatments are SGM‐affirmative remains understudied. Moradi and Budge (2018) emphasized the role of clinicians in creating SGM‐affirmative psychotherapies by challenging anti‐SGM attitudes and beliefs and promoting learning about the unique experiences of SGM individuals. Pachankis et al. (2023) developed overarching principles of SGM‐affirmative care based on prior affirmative psychotherapies and qualitative interviews with providers. Principles included providing psychoeducation about the connection between minority stressors and mental health symptoms, discussing the impact of early minority stressors on identity formation, encouraging strategies to cope with these stressors, and highlighting unique sources of resilience. Both studies also identified numerous examples of SGM‐affirmative psychotherapies that offered small or non‐significant advantages in mental health outcomes relative to nontailored psychotherapies, although neither performed a meta‐analysis. Overall, SGM‐affirmative adaptations to evidence‐based PTSD treatments may improve PTSD outcomes and serve to depathologize normative and expectable reactions to minority stressors, although very few RCTs of SGM‐affirmative treatments have been conducted (Heck et al., 2017; Pachankis & Safren, 2019).

Current study

The current systematic literature review was conducted to help determine the extent to which SOGI information is reported in PTSD treatment RCTs, SGM individuals are enrolled in these studies, and these treatments are differentially efficacious among SGM individuals. The current review builds upon Madnick and Spokas’ (2022) systematic literature review by focusing on a restricted set of interventions that have consistently been endorsed across clinical treatment guidelines; searching five additional databases; developing a more comprehensive and reproducible search strategy for the identification of SGM‐relevant keywords; including research conducted outside the United States; and including RCTs published up to August 7, 2025. To the best of our knowledge, no study has quantified the average proportion of participants in PTSD RCTs who were SGM. Such information could clarify the scope of potential underinclusion and the need for increased recruitment efforts for this population. Our research questions were: (a) To what extent have RCTs of CPT, PE, and/or EMDR reported participant SOGI information?; (b) To what extent have RCTs of CPT, PE, and/or EMDR reported enrolling at least one SM and/or GM individual?; and (c) Among included RCTs that reported enrolling at least one SM and/or GM individual, to what extent is there evidence for or against the efficacy of CPT, PE, and EMDR in reducing PTSD symptoms for these individuals?

Based on similar systematic reviews of depression, anxiety, and substance use, we hypothesized that less than 5% of included studies would report SOGI information or report enrolling at least one SGM individual. We also hypothesized that there would be no explicit analysis (e.g., stratification, subgroup analysis) of the efficacy of these interventions among SGM individuals present within the included studies. Given the growing awareness of the unique stressors this population faces, we hypothesized that an increase in reporting over time would be observed.

METHOD

This study was designated as nonhuman subjects research and exempted from review by the Institutional Review Board of Rush University Medical Center. This review was preregistered at Prospero (CRD42024608781) on November 30, 2024, and amended during the first round of screening to specify the quality assessment tool and procedure for identifying SGM‐relevant keywords. Records were not reviewed until after the preregistration was published. PRISMA reporting guidelines (Page et al., 2021) were utilized. A specific research protocol was not prepared for this study. A copy of the preregistration, a list of included and excluded studies, and the code used for analysis are available from the Open Science Foundation. Of note, we use sexual‐ and gender‐minoritized (i.e., SGM) rather than LGBTQ+ throughout this paper because it is a more inclusive term, and it allowed us to, when helpful, distinguish between SM and GM individuals. We use the term minoritized rather than minority to emphasize that minority status is not inherent to an individual but rather an active process.

Sources

We used PubMed/MEDLINE, Embase, CINAHL, PsycINFO, LGBTQ+ Source, PTSDPubs, Google Scholar, and the Cochrane CENTRAL Register to identify RCTs published on or before November 15, 2024. An updated search following the same procedures was performed for all RCTs published on or before August 7, 2025. We additionally searched the references of all included records that reported enrolling SGM individuals and retrieved studies based on these references if they seemed likely to report SOGI information based on the authors, title, and/or journal.

Study eligibility

Studies needed to meet the following inclusion criteria: (a) written in English; (b) peer reviewed; (c) RCT investigating the impact of CPT, PE, or EMDR on PTSD symptoms; (d) utilized a standardized measure of PTSD; (e) reported any PTSD outcome data (e.g., effect sizes of PTSD treatment response, maintenance of gains, percentage retaining diagnosis) across any length of time (e.g., midtreatment, posttreatment, follow‐up); and (e) enrolled individuals 18 years of age or older. Studies were excluded if they were a literature review, case study, or case series; protocol without outcome data; or represented scholarship that is typically not impartially peer reviewed (e.g., poster or symposium abstracts, dissertations, editorials, letters, commentaries).

The inclusion and exclusion criteria were designed to be broad and resemble the criteria used by similarly structured reviews (i.e., Heck et al., 2017). We excluded records that delivered CPT, PE, or EMDR concurrently with other talk therapies; studies delivering one of these interventions concurrently with medications (e.g., PE plus sertraline) were eligible. We otherwise allowed modifications regarding the pacing, format, modality, synchrony, and delivery of the interventions. We also allowed waitlist control, randomized multiple baselines, and within‐subjects study designs. Studies were eligible regardless of whether PTSD was the primary outcome. Studies did not need to stratify their sample by SGM status to be eligible for inclusion.

Search strategy

We developed generic search terms (Table 1) and then tailored them to each database or website's preferred syntax with assistance from Rush University Medical Center librarians. When possible, we used medical subject heading terms to automatically expand our queries. Based on consultations with the Rush University Medical Center's library team, we restricted some search terms to specific fields (e.g., title, abstract, publication type) to reduce the number of false positives. We did not use search filters due to their inconsistent implementation across databases.

TABLE 1.

Generic search terms.

Boolean combination	Search terms
	(“cognitive processing therap*" OR “cognitive therap*” OR “prolonged exposure*” OR “Eye movement desensitization” OR EMDR)
AND	(random* OR RCT)
AND	(PTSD OR posttraumatic)
NOT	(meta‐analysis OR “meta‐analyses” OR “literature review” OR “narrative review” OR “systematic review” OR “case report*” OR “case stud*” OR “clinical case” OR “nonclinical case”)

Note: Asterisks denote wildcard expanders of one or more characters.

Selection process

We exported files containing search results and uploaded them to Covidence (Veritas Health Innovation, 2025). Covidence automatically removed 3,065 duplicates at import. The first author then screened 100% of titles and abstracts against eligibility criteria within Covidence. Full‐text articles were procured from journal websites during the second round of screening, during which the first author spent approximately 10 min per record screening against the eligibility criteria.

The second author independently screened 25% of records during both the title and abstract screening processes, as well as the full‐text screening. The first and second authors had 100% agreement on the overall eligibility decision. Records were tagged with the first violation of eligibility criteria identified during both screening stages; therefore, we did not assess agreement between screeners on the specific criteria that had been violated.

Data collection process

During the full‐text review, the first author read demographic tables and sections that described participants or settings for mentions of SOGI information beyond binary sex or gender. The body of each record was additionally text‐searched for the following keywords: gay, LGBTQ, MSM (i.e., men who have sex with men), bisexual, orientation, queer, nonbinary, transgender, gender, and sex.

At the onset of data analysis, we conducted an additional search of included records for SGM‐relevant demographic keywords using a custom script described in greater detail in the preregistration. The script searched for keywords identified from glossaries published by three SGM advocacy organizations (i.e., the Human Rights Campaign, Trevor Project, and PFLAG) and produced strings of text that were manually reviewed to determine if they contained SOGI information that had been missed during the full‐text review; this search strategy identified no further records.

We modified a data extraction template provided by Covidence to track study details, including sample size; sample country; age (mean), sex, gender identity, and sexual orientation; overall study design; whether the study explicitly excluded SGM individuals; whether the study was a secondary data analysis; PTSD measures used; descriptions of treatments, including modifications, dose, and pacing; and the type of PTSD outcome reported (e.g., treatment gains, maintenance of gains, difference in scores, percentage meeting diagnostic status). For records that contained multiple eligible PTSD outcomes, we selected the outcome that was most relevant to the primary aim of the original record.

Responses to SOGI items that did not clarify whether a participant reported an SGM identity, such as “prefer not to say” or “other,” were not included when counting the number of SGM individuals enrolled. For all records that reported enrolling at least one SGM individual, the first and second authors independently completed the data extraction form and Revised Risk of Bias Tool (RoB2; RoB Team, 2020; Sterne et al., 2019) assessment. The RoB2 included five equally weighted domains of potential bias (randomization process, deviations from the intended interventions, missing outcome data, measurement of the outcome, and selection of reported results) that were averaged to provide an overall risk of bias judgment. We selected the RoB2 due to its widespread use in RCT literature reviews. Disagreements were resolved through monthly consensus meetings. When necessary, we retrieved supplementary materials, statistical analysis plans, and clinical trial records to assist with eligibility determinations, data extraction, and risk of bias assessment. As we aimed to review the current publicly available literature, we did not contact the authors of included studies to request additional information for the current study.

Data analysis and synthesis

Given that Madnick and Spokas (2022) identified only one PTSD RCT that reported enrolling SGM individuals, we decided a priori that a formal meta‐analysis was not feasible. Data synthesis consisted of creating descriptive summaries and tables, broken down with as much specificity as possible with regard to SGM subgroups.

RESULTS

We conducted a systematic literature review of CPT, PE, and EMDR RCTs across eight databases. Our search strategy returned a total of 5,011 records, 519 of which remained after deduplication and two rounds of screening (Figure 1).

FIGURE 1.

PRISMA Flow Diagram

Note: Created using Covidence (Veritas Health Innovation, 2025). SGM = sexual‐ and/or gender‐minoritized; CPT = cognitive processing therapy; PE = prolonged exposure; EMDR = eye movement desensitization and reprocessing; RCT = randomized controlled trial; PTSD = posttraumatic stress disorder.

Reporting of SOGI information

A total of 22 records that included SGM‐relevant keywords anywhere in the text, outside of the bibliography, were identified. Most of these studies (k = 12), however, did not report participant SOGI information beyond binary sex or gender. Specifically, these keywords were embedded in clarifications that such information was not collected (k = 7) or was included in discussions of study limitations (k = 3), discussions of HIV interventions (k = 1), and author positionality statements (k = 1).

Consistent with our hypothesis, 1.9% (k = 10) of included studies reported SOGI information (Table 2). These records spanned a diverse set of methodologies, authors, and outcome measures (Table 3) and were published between 2012 and 2025 (Mdn = 2023), whereas included studies that did not report SOGI data were published between 1994 and 2025 (Mdn = 2019). We did not identify any records that reported SOGI information and enrolled zero SGM individuals. Therefore, the percentage of records that reported enrolling at least one SGM individual is also 1.9%, in line with our hypothesis. Overall, SOGI information was measured inconsistently between studies (see Table 2).

TABLE 2.

Representation of sexual‐ and/or gender‐minoritized (SGM) individuals among studies that reported sexual orientation and gender identity (SOGI) information.

Study	Sample	Hetero‐sexual (%)	Sexual minoritized (%)	Female gender (%)	Gender minoritized (%)	White (%)	SOGI data
Bryan et al., 2024	157 U.S. military personnel and veterans with full or subthreshold PTSD	89.2	9.6	27.4	1.3	77.1	Models adjusted for gender, but the direction and strength of these effects were NR.
Burback et al., 2024	42 Canadian outpatients with suicidal ideation, 43% of whom had a trauma‐related disorder at baseline	59.5	33.3	73.8	4.8	69.0
Greenwald & Camden, 2024	96 crime survivors seeking treatment for PTSS	59.5	22.9	77.1	7.3	92.6	Reported nonbinary and transgender identities.
Kearney et al., 2021	184 veterans with PTSD recruited from VA medical centers	NR	NR	NR	0.5	58.2	Reported sex (16.3% female) but not gender. Models adjusted for sex, but the direction and strength of these effects were NR.
Molero‐Zafra et al., 2024	19 women in Spain experiencing PTSS from childhood sexual abuse	63.2	36.8	NR	NR	NR	Female sex was an inclusion criterion, but gender was NR.
Pacella et al., 2012	65 U.S. adults with comorbid HIV and likely PTSD	NR	NR	36.9	NR	38.5	Mean sexual orientation—rated from 1 (completely homosexual) to 9 (completely heterosexual—was 5.37 (SD = 3.59). The authors confirmed that sexual orientation was randomized between arms.
Park et al., 2025	227 U.S. adults who screened positive for PTSD or bipolar disorder	NR	NR	NR	2.2	67.0	Reported sex (78.4% female) and transgender/gender expansive identity.
Patterson et al., 2024	19 Canadian adults with comorbid psychosis, substance use, and a history of adverse events	57.9	42.1	21.1	26.3	73.7	Overall, 42% of the sample was part of the LGBTQ community.
Thorisdottir & Asmundson, 2022	90 Canadian adults with a lifetime history of distressing bullying	NR	NR	67.8	2.2	94.4
Weiss et al., 2025	193 German women with PTSD from childhood interpersonal abuse	66.3	30.1	100.0	0.0	NR	All participants reported female sex and gender identity.

Note: k = 10. The sexual orientation identity labels reported in these manuscripts were straight, heterosexual, homosexual, gay, lesbian, bisexual, asexual, pansexual, and queer. The gender identity labels reported in these manuscripts were female, woman, male, man, trans, transgender, nonbinary, and transgender/gender expansive identity. NR = not reported; PTSD = posttraumatic stress disorder; PTSS = posttraumatic stress symptoms; VA = U.S. Department of Veterans Affairs; LGBTQ = lesbian, gay, bisexual, transgender, and queer.

TABLE 3.

Design and risk of bias for sstudies tthat treported enrolling sexual‐ and gender‐minoritized (SGM) individuals.

Study	Study design	Experimental arm	Comparator arm(s)	D1	D2	D3	D4	D5	Overall
Bryan et al., 2024	Pragmatic RCT	Intensive CPT + crisis response planning a	Intensive CPT + self‐guided safety planning a	SC	LR	LR	HR	SC	HR
Burback et al., 2024	Pragmatic nonblinded RCT	Intensive EMDR + treatment as usual a	Treatment as usual	LR	LR	HR	HR	LR	HR
Greenwald & Camden, 2024	Pragmatic retrospective RCT	Intensive EMDR a	Intensive progressive counting a	HR	HR	LR	LR	SC	SC
Kearney et al., 2021	Noninferiority RCT	CPT	Loving‐kindness meditation	LR	LR	HR	SC	LR	HR
Molero‐Zafra et al., 2024	RCT with 8‐week baseline period	Trauma‐focused CBT	EMDR (group traumatic episode protocol)	HR	HR	HR	SC	SC	HR
Pacella et al., 2012	Partial crossover RCT	PE	Weekly monitoring/waitlist	LR	LR	LR	LR	SC	SC
Park et al., 2025	Pragmatic retrospective RCT	CPT	Case management and psychoeducation	LR	HR	LR	HR	SC	HR
Patterson et al., 2024	Randomized multiple‐baseline study	PE Plus	Baseline assessments conducted before PE Plus	LR	LR	SC	LR	LR	SC
Thorisdottir & Asmundson, 2022	Three‐arm partial crossover RCT	Asynchronous text‐based CPT	Asynchronous text‐based stress management or waitlist	LR	LR	LR	SC	SC	SC
Weiss et al., 2025	Retrospective RCT	CPT	DBT	LR	LR	SC	LR	SC	SC

Note: k = 10. RCT = randomized controlled trial; CPT = cognitive processing therapy; EMDR = eye movement desensitization and reprocessing; PE = prolonged exposure; DBT = dialectical behavioral therapy; LR = low risk; SC = some concerns; HR = high risk; D1 = randomization process; D2 = deviations from the intended interventions; D3 = missing outcome data; D4 = measurement of the outcome; D5 = selection of the reported result.

^a Intensive treatment is defined as more than one session per week.

Enrollment of SGM individuals

Across the 10 studies that reported enrolling SGM individuals, 132 of 1,092 total participants (12.1%) held an SM identity, and 24 (2.2%) held a GM identity. One record (Patterson et al., 2024) reported the percentage of participants who were a part of the overall SGM community in addition to reporting individual SGM subgroups. Contrary to our hypothesis, SGM individuals appeared to be numerically represented in RCTs at comparable rates to their prevalence in the overall population (9.3% in 2024; Jones, 2025) according to the available data.

Efficacy of CPT, PE, and EMDR among SGM individuals

As hypothesized, none of the studies included in the review explicitly assessed the efficacy of CPT, PE, or EMDR among SGM individuals (e.g., through stratification or subgroup analyses). Although several studies adjusted their models for sex and gender, they did not report on the direction or size of these effects or clarify how these variables were encoded. Therefore, the extent to which these treatments adequately serve this population remains unclear, as does the extent to which SGM‐affirmative modifications to these treatments may be necessary.

Risk of bias

Regarding our overall risk of bias judgments, five studies were rated as having “some concerns,” and five were rated as “high risk” (Table 3). The largest source of potential bias came from the selection of reported results; several studies included multiple eligible PTSD instruments or analyses of the data without providing a clear justification for the authors’ choice in the manuscript. These studies also typically lacked a prespecified analysis plan.

DISCUSSION

In our systematic literature review of CPT, PE, and EMDR RCTs, we found that although the reporting of participant SOGI information appears to have increased over time, it remains low at 1.9% of the included studies. When SOGI information was reported, SM and GM individuals, on average, comprised 12.1% and 2.2% of the sample, respectively. These percentages roughly match the prevalence of SGM individuals in nationally representative samples (9.3% in 2024; Jones, 2025), although it is possible that these percentages are not representative of other studies due to reporting bias.

To evaluate potential differences in the efficacy of these treatments between SGM and CH individuals, researchers should report whether PTSD treatment gains or maintenance of gains differed as a function of sexual orientation, gender identity, and transgender status in their manuscripts. To address the underreporting of SOGI data, researchers should explicitly report what SOGI information was collected and may be available for analysis, including descriptions of how questions were worded and response options. Peer reviewers can also request that authors clarify whether SOGI data were collected and ask for such information to be reported. Journal editors can establish guidelines for the reporting of SOGI information and issue calls for studies that evaluate the efficacy of PTSD interventions among SGM individuals. Individual actions, however, need to be paired with efforts to prioritize research on the specific mental health needs of SGM individuals. We are encouraged by an ongoing study by Flentje (2024) that is investigating some of these questions among a large sample of SGM individuals receiving either CPT or skills training in affective and interpersonal regulation narrative therapy (Cloitre et al., 2020).

Researchers may understandably be concerned about the potential misuse of SOGI data to harm participants and patients, such as the release of private health information, restrictions on gender‐affirming care they may receive, or the targeting of institutions that offer such care (e.g., Senate Finance Committee–Majority Staff, 2024; Zayhowski et al., 2025). However, given the importance of these data to better facilitate efficacious interventions, researchers should implement further and/or redundant measures to protect SOGI information, including developing procedures for sharing data with third parties and regulatory institutions, handling Freedom of Information Act requests, and limiting access to metadata (Office of the Chief Statistician of the United States, 2023).

SGM individuals deserve efficacious mental health treatments. The relative efficacy of CPT, PE, and EMDR among SGM individuals and the need for affirmative treatment modifications remain understudied. Madnick and Spokas’ (2022) review suggests that this was also the case for trauma‐focused CBT (TF‐CBT) and narrative exposure therapy (NET; Schauer et al., 2011). Until more evidence is available, we recommend utilizing current clinical treatment guidelines. The most recent American Psychological Association (2025) treatment guidelines, for example, recommend TF‐CBT, CPT, and PE as first‐line treatments for adults with PTSD, with cognitive therapy, EMDR, and NET recommended as second‐line treatments.

Several recommendations to make PTSD treatments more SGM‐affirmative were also identified while conducting this review, including placing an increased emphasis on substance use as a coping strategy for exposure to potentially traumatic events and minority stressors, applying the skills taught in treatment to patients’ real‐life experiences with minority stressors, and discussing the role of identity concealment and disclosure on symptoms (Flentje et al., 2025; Livingston et al., 2019, 2020). These modifications may allow evidence‐based treatments to more effectively target insidious traumatic experiences (Root, 1992) that typically do not qualify as DSM‐5 PTSD Criterion A events but are associated with significant distress. These modifications have largely not been empirically studied, and it is important to have a clear rationale for why developing such modifications would assist in reducing PTSD symptom severity to avoid further expansion of the research–practice implementation gap.

Strengths of the current study include the preregistration, use of reproducible methods, use of customized search terms for eight databases, and focus on the most widely researched and implemented PTSD treatments. Limitations of this study include the exclusion of RCTs of concurrent treatment of PTSD and substance use (COPE; Persson et al., 2017), which are perhaps more likely to enroll SGM individuals given the common co‐occurrence of these concerns in this population. We also did not have the resources to allow multiple reviewers to screen every included record, which may have resulted in the mistaken inclusion or exclusion of records. There was 100% agreement on the 25% of records that two authors individually screened, though we did not assess for disagreement on which eligibility criteria each rater thought had been violated. We similarly did not conduct a risk of bias assessment for every included study. Additionally, we did not assess for publication bias; studies that enroll more SGM participants may be viewed as less generalizable and, therefore, may be less likely to be published relative to studies that enroll more CH individuals.

More research is needed on the extent to which CPT, PE, and EMDR are effective at treating PTSD among SGM individuals. Such information may aid in the creation of empirically based SGM‐affirmative adaptations to extant treatments. Several such modifications have been proposed in the literature, though they have largely not been systematically investigated.

Beyond numerical representation of SGM individuals in RCTs, the extent to which the unique mental health needs of SGM individuals are being prioritized in treatment research remains understudied. Recently, several transdiagnostic treatments that specifically target mental health concerns common among SGM individuals have been developed, including a modified Unified Protocol intervention (Parsons et al., 2017), Empowering Queer Identities In Psychotherapy (EQUIP; Pachankis et al., 2025), Transdiagnostic LGBT‐Affirmative CBT (Pachankis et al., 2022), Still Climbin’ (Bogart et al., 2018), and others. More research is needed to understand the effectiveness of these interventions, especially for PTSD and in comparison to evidence‐based PTSD treatments.

OPEN PRACTICES STATEMENT

The data that supports the findings of this study are openly available from the Open Science Foundation at http://doi.org/10.17605/OSF.IO/SNWK4. That repository contains a copy of the preregistration, a list of included and excluded studies, supplemental files, and the code used for analysis.

AUTHOR NOTE

No specific financial support was received for this research. Philip Held receives grant support from the U.S. Department of Defense (DoD; W81XWH‐22‐1‐0739, HT9425‐24‐1‐0666, HT9425‐24‐1‐0637), Wounded Warrior Project, United Services Automobile Association (USAA), Face the Fight, and the Crown Family Foundation. Lia J. Smith's work is supported by the National Center for Advancing Translational Sciences of the National Institutes of Health (TL1TR002388).

The authors do not have any conflicts of interest to disclose. This content is solely the responsibility of the authors and does not necessarily represent the official views of the DoD, National Institutes of Health, Wounded Warrior Project, USAA, or any other funding agency.

We wish to thank the Rush University Medical Center library team for their help in designing the search strategy for this review and assisting in an updated search on August 7, 2025.

AUTHOR CONTRIBUTIONS

Marley Warren: conceptualization, methodology, software, investigation, formal analysis, writing ‐ original draft, visualization. Lia J. Smith: conceptualization, methodology, investigation, validation, writing ‐ review and editing, writing ‐ original draft. Sarah A. Pridgen: writing ‐ review and editing, supervision. Philip Held: writing ‐ review and editing, supervision.