Defying stigma

For LGBTQ people who suffer from isolation and shame, public health professor John Pachankis has devised a pathway to healing.

Steven Lance ’18JD is a Yale Law School Public Interest Fellow at the NAACP Legal Defense Fund.

Chris Cassidy

Chris Cassidy

"We have enough data that the treatment works,” says Professor John Pachankis. β€œThe next step should be to get it in the hands of LGBTQ people who need it most.” View full image

When she sent the first email, Krystn Wagner, the director of the HIV and infectious disease program at Fair Haven Community Health Care, had never worked with John Pachankis. But she was certain he was the right person to contact.

Wagner had noticed a recurring theme in conversations with her PrEP patients. PrEP—short for “pre-exposure prophylaxis”—is a revolutionary medication that can prevent an HIV-negative person who is exposed to the virus from being infected. Wagner ’89PhD, ’96MD, was the first clinician to bring PrEP to Fair Haven, a low-income, mostly Latino neighborhood about a mile from Yale’s campus, but separated from it by a highway, train tracks, and a narrow river. The patients she prescribed PrEP to were mostly gay and bisexual men at high risk of contracting HIV. Most of these men, like the majority of patients at the clinic, were men of color. In Connecticut and across the nation, as Wagner knew, the highest rates of new HIV infections are among gay and bisexual men of color—men like her patients.

Often, during visits at the clinic, Wagner and her PrEP patients discussed sexual and mental health. A conversation with one man in his 30s stayed in Wagner’s memory. He described nights when he would drink heavily, meet strangers at bars or on apps like Grindr or Tinder, have sex without condoms, and wake up feeling regret. Wagner asked if he talked with his male partners about using condoms.

“Look at this face,” he responded. “How could I?”

Another man on PrEP told Wagner he felt alone because his family in Mexico didn’t know he was gay. Family members called and confided in him about their lives, but he didn’t think he could tell them about his. He was depressed, and he was having condomless sex with men whose HIV status he didn’t know. Stories like these accumulated. They were variations on similar themes: negative self-image, isolation, fear of rejection, depression, anxiety, and sexual risk-taking. Addressing these issues, Wagner thought, could help these men stay HIV-negative.

One afternoon in June of 2017, Wagner went to a talk at Yale’s Center for Interdisciplinary Research on AIDS. The speaker was a postdoc in John Pachankis’s lab at the School of Public Health. As Wagner listened, the postdoc summarized a study taking place in Miami and New York with over 250 participants, all young gay or bisexual men. Pachankis, who is the Susan Dwight Bliss Associate Professor of Public Health, and his research group had designed a model of cognitive behavior therapy tailored to the unique stressors LGBTQ people face because of stigma. They called the treatment “Esteem.”

Over ten weekly sessions, each with its own topic, participants learned how exposure to stigma-related stress might be affecting their mental health and health behaviors. They practiced coping strategies. The treatment encouraged them to see their sexuality as healthy, and to think of LGBTQ identity as a source of strength. Already, Pachankis and his team had data from a smaller pilot study suggesting that Esteem (an acronym for “Effective Skills to Empower Effective Men”) worked. These preliminary results were promising: participants who received the treatment showed fewer symptoms of depression and anxiety, more assertiveness, and less internalized homophobia. They reported lower levels of substance use and less condomless sex with casual partners.

Wagner emailed Pachankis the next day. Could they bring it to New Haven?

For Pachankis, the stories Wagner shared resonated. “The ultimate goal of my research,” Pachankis told me recently, “is to help young LGBTQ people feel less alone and more supported in their journey.” So, when Wagner suggested that trying the treatment in Fair Haven was a perfect opportunity to do this, he agreed. The two met in Pachankis’s office at the School of Public Health and got to work on a grant application.

By 2017, Esteem was already four years old. But its roots went back further. Pachankis, who is 39 years old, grew up in Shreveport, Louisiana. He remembers it as the kind of place where the first question people ask is which church you go to. Like his neighbors, Pachankis was raised religious, attending Catholic school through eighth grade. Among most of the adults he encountered, homophobia was a given—an implicit legacy of the institutions and society that had shaped them. “There were simply no models of love and tolerance for LGBTQ people in the place at that time,” Pachankis says.

Back then, Pachankis remembers, places like Shreveport had two messages for young gay men. “There was a message from your church that you were going to hell,” he says, “and a message in the newspapers that you were going to die of AIDS.”

“That’s how I learned about my identity,” he says. “When those are the lessons, you either mentally succumb to that or you say: ‘This can’t be true, and I’ve got to prove to myself and other people that it’s not true.’”

Pachankis chose the latter route. He had always been an avid reader; childhood trips to used bookstores and libraries with different grandparents blur together in his memory. “I loved going to those places,” he says. “I would get lost in the library, in the stacks.” He found himself drawn to Freud, Jung, and old psychology textbooks—books he enjoyed, even if his motivation for reading them was partly terror. His mother’s brother had been institutionalized with schizophrenia from childhood. Pachankis worried the same thing would happen to him. “I knew I was different; the world told me I was different,” he says. “But I couldn’t really label it. And I would think, ‘Is that difference because I might have schizophrenia, or is it because I’m gay?’”

Fear of state asylums pushed Pachankis to put his curiosity to work. “I’m going to be locked up in the hospital,” he remembers thinking, “unless I put all my energies into solving this.” So he absorbed everything he could find about the science of mental illness, like a boxer studying an opponent’s footwork. “How can I save myself from this happening to me?” he wondered. “Then it came back to saving myself from dying of AIDS, and to saving myself from going to hell.”

After high school, Pachankis was offered a scholarship to Loyola University. He took it—Loyola’s campus is in New Orleans, “the nearest liberal big city.” Shortly after leaving Shreveport, he wrote his grandfather a letter telling him that he was gay. Pachankis’s grandfather, a man who had grown up on the South Side of Chicago and served as a flight navigator in the Air Force, wrote back. Pachankis still has the letter. “The thing that’s gotten you through so far is that you’ve studied hard,” he remembers his grandfather writing. “And, you know, if you can apply the same skills to navigating the challenges that you’ll face as a gay man in the Deep South, I think it will serve you well.”

It was good advice, Pachankis says, even if his grandfather probably couldn’t have guessed where it would lead. “I don’t think he intended that I would pursue his advice so literally—that I’d be studying LGBTQ life and health and community for my career.” But the navigator’s intuition was right. “By knowing everything I could know about the world that awaited me, and the community that I was inheriting by virtue of being gay, I would have a good life.”

In New Orleans, Pachankis became an HIV testing counselor for the NO/AIDS Task Force. Through this work, he met the city’s old guard of LGBTQ activists, people he describes as “real community heroes” who “opened my eyes to ways that we could all play a part in helping build that community.” Pachankis’s mentor at Loyola, a psychology professor, introduced him to LGBTQ friends—successful, thriving people. “It was really the first time I saw, firsthand, models of happy, healthy gay adult life,” Pachankis recalls. He wanted to be part of it. And as he learned more about the community he was inheriting, the virulent impact of AIDS became concrete. While Pachankis was still in college, his mentor’s partner died. Pachankis saw the disease take a toll on friends and people he counseled. “It was my community, so I was personally involved in this,” he says. “But it was also a community in need of answers, and in need of help and support. And it became clear what my role in the community could be.”

After graduating in 2002, Pachankis enrolled in a PhD program in clinical psychology at the State University of New York at Stony Brook. It was a way to continue the work he had started in New Orleans. By then, he remembers, “I knew pretty clearly what I wanted to do: to help LGBTQ people and the LGBTQ community thrive.” He found an externship in Manhattan, working as a therapist with gay and bisexual men as part of an HIV-prevention program. His patients’ stories included themes he describes as “deep-rooted legacies of the closet”: not feeling confident or assertive, anticipating rejection, and feeling that one’s self-worth depends on the approval of others. “I saw a lot of unmet needs gay and bisexual men had that they hadn’t previously expressed to anyone,” Pachankis recalls. But formal coursework provided little guidance on how to meet these needs. There was no manual on LGBTQ mental health care. He did his best, drawing on his own experiences. “But I did wonder,” he says, “if there were general principles or treatment techniques that could be consistently applied within the LGBTQ population in particular.”

As Pachankis was running up against the limits of a one-size-fits-all approach to mental health, a shift was under way in his field. For the first time, researchers had access to population-level data showing that lesbian, gay, and bisexual people are at disproportionate risk for stress-related mental health problems. Compared with heterosexual people, they face higher risk of depression, anxiety, and substance use problems, and are more likely to have suicidal thoughts. Gay men are more likely to attempt suicide than heterosexual men. By the early 2000s, Pachankis says, the problem was clear. The question for psychologists became: “Why?”

In his first year at Stony Brook, Pachankis encountered a recent paper by the social psychologist Ilan Meyer proposing an answer. The reason LGBTQ people experienced more mental health problems than heterosexual people, Meyer argued, was that they were exposed to more stress as a result of stigma against them. Meyer’s explanation—“minority stress”—struck Pachankis as right. Meyer became one of Pachankis’s professional role models and mentors. When he met Pachankis, Meyer told me, “I was immediately impressed by John’s intellect and the depth of his work.” Pachankis immersed himself in the growing evidence that stigma-related stress was driving the issues he had seen in clinical work. Now, there was a persuasive account of why. Pachankis’s mind jumped to the next question: How can we intervene to change that?

Answering that question has become Pachankis’s life’s work.

In 2013, Pachankis came to Yale. He had just received a grant to conduct a treatment study—hoping to fill a need he’d been aware of since grad school. “Until our work,” he says, “there had been no mental health treatment that had ever been tested for efficacy specifically with LGBTQ people.” Pachankis set out to change that. He interviewed dozens of LGBTQ people about their experiences with psychotherapy and gathered insights from therapists who worked with LGBTQ patients. Then, says Pachankis, “we distilled all that clinical wisdom, all the stories that we heard from LGBTQ people, and packaged them into a treatment manual.” The next step was testing it in randomized control trials. The second of these was under way when Krystn Wagner emailed from Fair Haven.

To adapt the treatment for Wagner’s patients, Pachankis and his colleagues interviewed gay and bisexual men of color in greater New Haven and made changes in response to their feedback. First, they revised the program’s content to address intersectional stigma—based on race as well as sexual orientation. Second, to counteract the isolation of being LGBTQ in a small urban area, they added an emphasis on community—and changed the format from one-on-one therapy to group counseling.

To find participants, they contacted community organizations and health centers. They ran ads on Facebook and Grindr. They set aside funds for a small transportation stipend. In November 2018, the study began. Over ten weeks, well into a New Haven winter, about ten men gathered every Tuesday night at Wagner’s clinic in Fair Haven. A second cohort met there in the spring.

Skyler Jackson, the therapist for the winter study, described the group as “a really diverse cross-section of gay and bisexual black and Latino men.” As Jackson reported back to his colleagues on each week’s progress, Pachankis sensed that the treatment was addressing an important need. After the study, they conducted qualitative interviews with the participants, and the men’s responses confirmed his impression:

“I used to think that being gay was a bad thing, and . . . that I should be ashamed of myself, that I should try and be straight, and that I shouldn’t hang out with, like, other gay people.” Now, it’s “the exact opposite.”

After the study, “I came out to my mom. I came out to a lot more friends. . . . Now, I’m just like—I’m just living my best life, as people say.”

“It helped me a lot to . . . how do I say it—be happy with myself, like accept myself. [In the sessions,] people . . . actually listened and cared about what I had to say.”

The sessions “made me feel like I wasn’t alone.”

Feeling less isolated after the study was a major topic in the responses, Jackson says: “The sentiment was expressed so regularly, and without prompting in our questions—we were astounded.” In addition to the qualitative interviews, the researchers also gathered data about participants’ mental health, substance use, sexual health, stigma coping, and concerns related to their LGBTQ identities. Across the outcomes they measured, Jackson said, “gay and bisexual men of color in New Haven are faring better for participating in this group.”

This year, Pachankis and his colleagues will publish a manual other clinicians can use to provide the Esteem treatment to their patients. The working title is “LGBTQ-Affirmative Cognitive Behavior Therapy,” and it’s under contract with Oxford University Press. They’ve also run trials testing variations on the delivery model—for example, a New York study of a treatment adapted for LGBTQ women and a study in Romania of a treatment incorporating some Esteem skills, delivered via chat. Data is still coming in. “But we have enough data that the treatment works,” Pachankis says. “The next step should be to get it in the hands of LGBTQ people who need it most.”

For Pachankis, this means delivering it in high-stigma environments, where laws tell LGBTQ people they are not accepted and there is little access to LGBTQ-affirmative clinicians or resources. “One of the cruel parts of structural stigma,” he says, “is it keeps the people who most need effective treatments like this the furthest away from them.” He and his colleagues have prepared a self-guided, online version of Esteem, which includes regular check-ins with a live therapist.

They tested the online treatment in a small pilot last semester. In mid-February, they began a clinical trial with 250 participants. If it proves effective, the online model may enable them to help people in places like the northern Louisiana of Pachankis’s childhood, where stigma is widespread.

Reaching people like these motivates Pachankis. “A clear image I have in mind when I think about what my research goal is,” he told me, “is of an LGBTQ young person who comes home from school after a day of being bullied and teased and thinking that they’re all alone, who has a secret that they’ve never shared with anyone else, wondering what life awaits them on the other side of the closet.” Pachankis wants that young person to have support—and access to effective treatment. “The goal of my career,” he says, “is to think of ways that we as scientists and clinicians can ensure that no LGBTQ person feels that they’re alone in this.” 

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