Background

Comparing Two Ways to Help Sexual and Gender Minority Men Who Have Been Sexually Abused Reduce Depression and Increase Mental Health Treatment Engagement - NCBI Bookshelf An official website of the United States government Here's how you know The .gov means it's official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site. The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely. 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Ellis , PhD, Vanessa Simiola , PsyD, Maria O'Connell , PhD, Chyrell Bellamy , MSW, PhD, and Steve Martino , PhD. Author Information and Affiliations Authors Joan M. Cook , PhD, 1 Amy E. Ellis , PhD, 2 Vanessa Simiola , PsyD, 3 Maria O'Connell , PhD, 1 Chyrell Bellamy , MSW, PhD, 1 and Steve Martino , PhD 1,4 . Affiliations 1 Yale School of Medicine, New Haven, Connecticut 2 Nova Southeastern University, Fort Lauderdale, Florida 3 Kaiser Permanente, Center for Integrated Health Care Research, Honolulu, Hawaii 4 Department of Veterans Affairs Connecticut Healthcare System, West Haven Washington (DC): Patient-Centered Outcomes Research Institute (PCORI) ; 2023 Sep . Copyright and Permissions Copyright © 2023. Yale University. All Rights Reserved. This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License which permits noncommercial use and distribution provided the original author(s) and source are credited. (See https://creativecommons.org/licenses/by-nc-nd/4.0/ Structured Abstract Background: Sexual abuse of boys and men is a public health problem that has received little attention from clinical scholars and researchers. Given unique pathways for development of and recovery from trauma-related emotional distress, sexual abuse survivors who identify as men may need distinct interventions to promote engagement in formal mental health care and assist in psychiatric symptom reduction. Sexual minority male individuals (ie, people who are not heterosexual or straight [eg, gay, bisexual, pansexual, queer]) and gender minority male individuals (ie, people who are not cisgender; anyone who identifies as transgender or gender divergent) are at higher rates of sexual victimization than heterosexual or cisgender male individuals. Objectives: This is a comparative effectiveness randomized controlled trial comparing the effectiveness of motivational interviewing (MI) and MI with affirmative care (MI+AC) for sexual and gender minority (SGM) men who have been sexually traumatized. Affirmative care involves validation of unique stressors facing SGM people (eg, discrimination, minority stress) and promotion of safe, identity-supporting networks. The first specific aim was to train men with lived experience of sexual abuse or assault as peer leaders to deliver MI and MI+AC in online groups with integrity and efficacy. The second specific aim was to determine the comparative effectiveness of MI and MI+AC on 2 primary outcomes (mental health treatment engagement and depression). The third specific aim was to examine SGM trauma survivors' past mental health treatment experiences, perspective on the study peer-led interventions, and preferences for future mental health treatment. Methods: Social media platforms were used to recruit SGM men with a history of unwanted sexual experiences and difficulties with stress. A total of 2042 participants completed the screen, and of those, 2021 had a history of unwanted sexual experiences. Of those 1346 were excluded for various reasons (see flowchart for more details) and 696 completed the phone screen. Of those, 403 completed the baseline and 356 were randomly assigned. Sexual and gender minority male sexual assault survivors (N = 356; ages = 18 to 75 years, mean age = 35 years; 41.9% racial and ethnic minorities) who reported at least mild depressive symptoms and were not currently in mental health treatment were randomly assigned to either group, with assessments at baseline, postintervention, and 60- and 120-day follow-up. The primary hypotheses are that participants assigned to MI+AC, compared to those in MI only, would report greater reduction in symptoms of depression (as measured by self-report on the Center for Epidemiologic Studies Depression Scale) and higher levels of engagement in formal mental health treatment (ie, those who endorsed having 1 or more visits or scheduled appointments to any mental health services in the past 2 months). Additional hypotheses relate to secondary outcomes, including posttraumatic stress disorder (PTSD), dissociation, suicidality, psychosocial functioning, and substance use. Primary analyses included linear mixed models (LMMs, for continuous variables) and generalized estimating equations (for categorical variables) testing for main effects of time and condition and the effect of the interaction between time and condition on each dependent variable. Results: A total of 32 peers were trained to deliver MI or MI+AC, of whom 23 co-led at least 1 group. We used LMMs and generalized estimating equations to assess the impact of the intervention on outcomes over time. There were no significant main effects for condition or condition × time interaction effects in both study arms on 1 of the primary outcomes, depression, with most participants experiencing a significant decrease in depressive symptoms over time. Of those who experienced severe depression at baseline, however, a greater proportion of MI+AC participants experienced a reduction in depressive symptoms compared with those in MI so that they no longer qualified as being at high risk for severe depression at the postintervention and 2-month follow-up periods (postintervention: β = −.14 [95% CI, −.24 to −.04], P = .006; 2 months: β = −.13 [95% CI, −.24 to −.03], P = .01). There were no significant main effects for condition or interaction effects in terms of the other primary outcome, initiation of mental health treatment or subsequent number of mental health treatment sessions attended, with most significantly increasing initiation over time. Conclusions: Most SGM male survivors in this trial, regardless of whether they received MI or MI+AC, experienced significant decreases in depression, PTSD, substance use, psychosocial impairment, and suicidality and an increase in initiation of formal mental health treatment. The fact that both conditions were associated with improvements seems to support the positive impact of goal-directed, validating peer support for SGM male survivors in the context of MI with or without formal AC. Without an untreated control group, however, more firm conclusions on treatment efficacy cannot be drawn. This study demonstrates the feasibility and effectiveness of training peers to deliver MI online in group format to SGM male survivors. Limitations: This study relied on retrospective reporting of trauma on an online self-report screener and thus is prone to recollection or reporting bias. It is possible that some men who completed the screening did not label their unwanted sexual experiences as sexual victimization. Relatedly, this study relied on self-report of sexual orientation identity. This study relied on a self-selected sample, obtained through social media and marketing strategies, of people who elected to seek out study participation. Thus, this sample may overrepresent people who are comfortable disclosing their sexual orientation and sexual trauma history. This trial contained 2 active interventions, and there was no untreated control group, so any baseline to follow-up effects reported cannot definitively be attributed to the interventions. Background One in 6 men is sexually abused before their 18th birthday, 1 and this number rises to 1 in 4 men who experience some form of sexual assault across their lifespan. 2 Survivors of sexual abuse and assault are at risk for a wide range of medical, psychological, behavioral, and sexual disorders. 3 Indeed, sexual trauma is related to numerous psychiatric disorders, including posttraumatic stress disorder (PTSD), substance abuse and dependence, depression, and suicidal behavior. 1 , 4 Men with histories of childhood and adult sexual victimization are more likely to report greater numbers of sexually transmitted infections, higher sexual risk for HIV, and higher sexual compulsivity than men with no history of sexual assault. 5 In addition, men who have experienced sexual trauma report significantly greater educational, occupational, and relationship difficulties than nonabused men. 6 Sexual trauma is also linked to medical illnesses, increased health care utilization, and poor quality of life. 3 , 7 , 8 Sexual and gender minority (SGM [ie, those who identify as gay or bisexual, engage in same-sex sexual behavior, or are transgender or nonbinary]) survivors of sexual trauma are exposed to sexual violence at higher rates than the general population. 9 In addition, SGM people often experience significant levels of minority stress because of the prejudice and discrimination they face at home, in the workplace, and in society. 10-14 Furthermore, gay and bisexual men are significantly more likely than heterosexual men to report experiencing depression, anxiety, alcohol use, and sex-risk behavior. 5 Although SGM male survivors (ie, those who have had unwanted sexual experiences) suffer significant psychological distress and disorder, it appears they do not often seek formal mental health treatment, or they take years to do so. In general, men seek mental health assistance at disproportionately lower rates than women. 15 Similarly, in survivors of a broad range of traumatic events and PTSD, decreased mental health service use was related to being male. 16 In addition, despite similar rates of sexual trauma experienced by men and women during military service, men are less likely to seek and use professional help. 17 Men are even less likely to seek counseling when they have been most severely assaulted (ie, experienced penetration). 18 Through our Eugene Washington PCORI Engagement Award, and consistent with past research, 19 male sexual abuse survivors explained their difficulties in seeking formal mental health services. In part, they cited distrust when coming into contact with perceived authority figures, such as health care professionals. In addition, when male survivors considered initiating mental health services, they had difficulty finding knowledgeable and experienced professionals who understood the nuances specific to male sexual abuse 20 and, consequently, infrequently disclosed their sexual trauma and related difficulties. 21 Moreover, stigma related to sexual orientation and identity is one of the most often cited barriers to seeking mental health help for SGM people. Conformity to rigid and unhelpful beliefs about masculinity may underpin such stigma. 15 Traditional male socialization practices convey a number of messages that probably decrease mental health care participation, such as that boys should always be powerful and invulnerable, they should never cry or experience sadness, and a boy or man should always welcome sexual activity. 22 , 23 In addition, male survivors of sexual abuse or assault at our PCORI Engagement Award focus groups stressed the importance of peer support in their recovery. Indeed, they explained how they initially choose to participate in online communities or chat rooms to reduce their emotional distress, without the associated stigma, shame, or cost of formal mental health services. This is consistent with findings from other studies. For example, recent research found that lesbian, gay, bisexual, transgender, queer, intersex, asexual, and all sexual and gender (LGBTQIA+) youth are more likely than non-LGBTQIA+ youth to have online friends and view them as more helpful than in-person peers at providing emotional support. 24 Thus, because of societal, familial, and internalized stigmatization, SGM male survivors may find online peer support particularly beneficial. Opportunities for peer-based support are common in mental health care, as evidenced by the use of mutual self-help groups (eg, 12-step groups). 25 The use of trained peers, however, is somewhat less common but becoming more prevalent in some service systems. In fact, studies show that peer specialists improve client engagement in treatment 26 along with numerous other advantageous outcomes, such as increased feelings of acceptance by others and decreased identification with stigma as a barrier to future actions. 27 Most notably, peer support can aid in the recovery process, increasing hope for the future and a sense of empowerment. 28 Recently, peer support has been found effective in facilitating positive outcomes for trauma-specific treatment for PTSD and substance use in a PCORI-funded project. 29 Peer-delivered interventions have also been used with the SGM community, including LGBTQIA+ people. 30 Motivational interviewing (MI) 31 , 32 is an evidence-based psychotherapy designed to help people resolve ambivalence about making positive behavioral changes and has promise as an approach that trained peers could use to guide SGM male survivors to enter formal mental health treatment. Indeed, there is some evidence of the utility of MI to increase intent to engage in mental health services and reduce mental health symptoms in other populations. 33-35 In addition, MI can be delivered in a group format, with demonstrated efficacy for improving treatment engagement and outcomes for adults with coexisting mental health and substance use problems. 36 Motivational interviewing has also been adapted for online interventions with significant treatment effects. 37-39 Although originally empirically validated for reducing substance misuse, MI is currently used to help people develop motivation to change a variety of health-related problem behaviors (eg, treatment nonadherence, poor weight management) and mental health problems highly comorbid with trauma (eg, depression, anxiety). 40 , 41 Motivational interviewing has been used as standalone or adjunct intervention to help people engage in more intensive mental health services, 33 , 34 which may in turn improve treatment outcomes for depression, 40 PTSD, 41 and substance misuse. 42 For example, in a sample of US veterans who served in wars in Iraq and Afghanistan and had subsequent mental health difficulties, 4 sessions of telephone-delivered MI increased intent to engage in mental health services and resulted in some improvements in mental health symptoms. 34 In addition, among depressed and anxious college-age men, MI had a small to moderate effect on both professional and nonprofessional help-seeking behavior. 35 Moreover, MI was used to increase and promote healthy behaviors in SGM people (ie, increased safe sex behaviors, decreased substance use). 43 , 44 Incorporating modules aimed at SGM minority stress, traditional masculinity, and male sexual abuse myths probably adds to MI in increasing the potential effectiveness in engaging SGM male survivors in mental health care. Findings from a recent randomized clinical trial support the utility of MI to significantly reduce both unprotected anal intercourse and recreational drug use among young SGM men. 43 Another recent clinical trial, however, incorporated 6 core principles of SGM affirmative care (AC) into standard cognitive-behavioral practice (including MI) and compared this adapted treatment with a wait-list control. 45 That trial demonstrated greater reductions in depression, alcohol use, and sexual compulsivity among young SGM men. These men may need an AC approach that integrates gender- and SGM-based principles alongside a comprehensive understanding of the adverse consequences of trauma on mental health. In a study of men with childhood sexual abuse histories, participants who received a male-centered group treatment experienced improvement in depression and PTSD symptoms. 46 In addition, several clinical scholars 47 called for interventions that specifically address masculinity stereotypes within an AC framework. These authors noted that interventions aimed at exploring masculinity and sexual orientation in the context of interpersonal sexual assault would probably be of great benefit to SGM men. Gender-based principles 48 derived from research on the psychology of men and male help seeking are also important. Male survivors, and more specifically SGM male survivors, have unique needs that require a trauma-informed approach. Hopton and Huta 46 evaluated the treatment effects of a male-centered curriculum focused on gender role issues and abuse. Discussion of the impact of sexual abuse on identity as men is paramount. Among the 114 men who received this treatment, there was overall improvement in depression and PTSD symptom scores. The authors noted a significant difference between those who completed treatment and those who did not, and they specifically called for future research and programming to address treatment ambivalence, noting in particular the use of MI for difficult-to-engage clients. This project evaluated the comparative effectiveness of MI and MI with AC (MI+AC) for SGM men with sexual trauma histories, delivered online by peers, men with lived experience of abuse or assault. The first specific aim was to train peer leaders to deliver MI and MI+AC in online groups with integrity and efficacy. The hypothesis was that peer leaders could deliver both versions of MI with adequate adherence and competence and use significantly more AC content in MI+AC than MI. The second specific aim was to determine the comparative effectiveness of MI and MI+AC on 2 primary outcomes (mental health treatment engagement and depression). The third specific aim was to examine SGM trauma survivors' past mental health treatment experiences, perspective on the study peer-led interventions, and preferences for future mental health treatment. Patient and Stakeholder Engagement This project was a collaborative partnership between Yale University and 2 community-based nonprofits: MaleSurvivor ( https://malesurvivor.org ) and MenHealing ( https://menhealing.org ). MaleSurvivor is a 501(c)(3), nonprofit, public benefit organization committed to preventing, healing, and eliminating all forms of sexual victimization of boys and men. Formed in 1995, MaleSurvivor facilitates dialogue among survivors as well as between survivors and professional therapists through their moderated online Support Forum, online 24/7 chat, and in-person events. MenHealing began in 1988 and over time developed a Weekend of Recovery program, delivering structured protocols for healing retreats. One goal of MenHealing is to expand accessibility for underserved populations of male survivors. In addition, a community-based advisory board met with the project team biannually to provide feedback on study design and execution, including the development of recruitment materials (eg, website, flyers, advertisements), identification and enlistment of participants, and plans to share the study results in formats most useful to the public. The advisory board consisted of 2 professional members, 2 professional members who were also survivors (SGM masculine-identifying people with lived experience of sexual abuse or assault), and 4 male community members who identified as survivors. The team also maintained ongoing phone and email contact with advisory board members. The team also collaborated with peer leaders and advisory board members in developing the screening and surveys. After the team sent them PDF versions of the surveys and requested their feedback (eg, content, order, clarity), some omissions and areas of confusion were highlighted and addressed. Methods Study Overview This study was designed to be a randomized comparative effectiveness trial of MI vs MI+AC 6-week groups that were peer delivered, online, and for SGM men who are sexual trauma survivors. Motivational interviewing is an evidence-based, patient-centered approach that explores and develops patients' motivation and commitment to change within a collaborative, highly empathic patient-clinician relationship. It blends fundamental patient-centered counseling techniques (eg, reflective listening) with advanced strategic methods (eg, developing discrepancies between important life goals and current behavior) to elicit patient statements that favor change (called “change talk”) and diminish those that argue against change (called “sustain talk”). Originally empirically validated for reducing substance use disorders, MI is now used to help people develop motivation to change a variety of other health-related problem behaviors (eg, treatment nonadherence, poor weight management) and mental health problems highly comorbid with trauma, such as depression, anxiety, and eating disorders. Incorporating modules aimed at SGM minority stress, traditional masculinity, and male sexual abuse may add to MI's efficacy in engaging SGM male survivors in formal mental health care and reducing depressive symptoms. Affirmative care revolves around 6 clinical principles and techniques to address mental health problems in SGM men: normalize mental health consequences of minority stress; rework negative beliefs stemming from early and ongoing minority stress experiences; empower SGM men to communicate openly and assertively across contexts; validate SGM men's unique strengths; affirm healthy, rewarding expressions of sexuality; and facilitate supportive relationships. Randomization was based on a list of computer-generated random numbers with stratification by treatment status: treatment naive vs treatment experienced (prior mental health treatment but not within the past 60 days). A total of 2042 people completed the online screen for the study, 696 completed the subsequent phone screen, 403 completed the baseline survey, and 356 participants were randomly assigned to MI or MI+AC in 25 cohorts, with an equal number of participants in each group. The first specific aim was to train peer leaders to deliver MI and MI+AC in online groups with integrity and efficacy. The hypothesis was that peer leaders could deliver both versions of MI with adequate adherence and competence and use significantly more AC content in MI+AC than MI. The second specific aim was to determine the comparative effectiveness of MI and MI+AC on 2 primary outcomes (formal mental health treatment engagement and depression). The third specific aim was to examine SGM trauma survivors' past mental health treatment experiences, perspectives on peer-led interventions, and preferences for future treatment. Assessments occurred at baseline, postintervention, and 60- and 120-day follow-up ( Figure 1 ). Figure 1 Study Design Overview. Study Setting This study used a video teleconference platform (Zoom) to create a digital health intervention (DHI) that reached SGM men across North America. DHIs provide flexibility by allowing participants to access help from the privacy of their home. Compared with face-to-face interventions, less motivation and effort are needed to initially access a DHI. 49 These interventions offer an opportunity to rapidly provide mental health help to masculine-identifying SGM survivors across the United States and Canada, at little cost, during a time when pandemic restrictions and concerns impeded in-person visits. Participants Recruitment and Training of Peer Leaders Peer leaders from across the United States and Canada were recruited to lead the interventions. More specifically, we recruited peer leaders from MaleSurvivor and MenHealing in March 2019. The executive director, Jim Struve, LCSW, of MenHealing, is on our advisory board and agreed to share our recruitment materials on their website and at workshops he conducted around the country. Inclusion criteria were 18 years of age or older, English-speaking, living in the United States or Canada, male gender identity, and history of sexual trauma. No rigid criteria were used to determine who might be a credible, effective peer leader. We conducted a search of the empirical literature with regard to the characteristics that might make for a strong peer leader. In addition, we discussed these findings with our co-investigator, Chyrell Bellamy, MSW, PhD, an expert on peer-led mental health services. We did not have rigidly set inclusion and exclusion criteria for peer leader participation. Rather, general, evidence-informed guides were used to make decisions. Potential peers were screened over a 30- to 45-minute telephone call. Joan Cook, PhD, principal investigator, and Amy Ellis, PhD, co-principal investigator, conducted the interviews and listened for the ability to express compassion, desire to help others, and use of shared experiences to the benefit of other people, which are all general areas for selection of strong peer leaders. 26 , 27 In addition, they listened for any transphobic, biphobic, or homophobic language or sentiments and for at least a cursory knowledge or interest in working with SGM people. We did not ask detailed questions about the nature or severity of peers' sexual abuse experiences or assess whether they met criteria for a mental health disorder. Rather, we asked questions and listened as to whether the candidates would be able to function as credible role models and coaches to the SGM male survivor population. Many of the peers we interviewed spontaneously discussed their own mental health recovery stories and described how hearing other male survivors' stories was a key part of their own healing. In our conversations with potential peer leaders, we listened for how the men might be able to effectively leverage their recovery stories to build rapport and trust and to promote hope in others. We tried to pick up on their insights into the impact of sexual abuse in their own lives, including internalized stigma and ways they addressed it. We also listened for whether and how the men took active roles in their own lives, health care, and recovery. We paid particular attention to whether and how the men expressed compassion and commitment to helping others. During these telephone calls with potential peer leaders, we also provided information about the study as well as study expectations and requirements (eg, computer and audio technology, participation in groups and supervision, attendance at in-person training). After completing more than 25 telephone calls with potential peer leaders, we successfully enrolled 20 people to co-lead the study interventions (cohort 1). On May 4 to 6, 2019, a 3-day in-person training for peers was held at Yale University. All peers attended the in-person workshop led by Drs Cook, Ellis, and Bellamy; Vanessa Simiola, PsyD; Steve Martino, PhD; and Joel Filmore, EdD, LPC, and received formal training in MI and trauma-informed SGM AC. Before the in-person meeting, and at the suggestion of our MI expert, Dr Martino, we sent each peer a copy of the book Finding Your Way to Change: How the Power of Motivational Interviewing Can Reveal What You Want and Help You Get There . 50 We asked the peers to read the book and try to complete the exercises before the meeting. The first day of the in-person meeting included a welcome and introduction, as well as key presentations on “The Essential Elements of Peer Support and Running Groups” and “LGBTQ+ Sensitivity Training.” The bulk of the training focused on MI. Peers provided informed consent and completed pretraining and posttraining assessments to assess their beliefs about and knowledge of MI and to collect basic information, including demographics and reasons for wanting to engage in peer work. The in-person training was videotaped for use in future trainings of peers. Although the peers reported benefiting greatly and learning a lot during the meeting, most expressed concern that they did not feel comfortable or confident with their ability to co-lead a group. The team discussed ways to address this issue. In discussions with peers we decided to greatly bolster the training materials. Dr Ellis took the lead in creating 12 MI training videos (6 for the MI condition, 6 for the MI+AC condition) to provide peer leaders with full examples of each session and in developing additional training materials (detailed manuals, in-session and at-home activities) for both conditions. Each video simulated each of the 6 sessions of the MI and MI+AC conditions. We worked closely with Dr Oscar Rojas Perez, a postdoctoral fellow at Yale with expertise in MI, in creating the videos, particularly because he and Dr Ellis served as the therapists for the mock therapy sessions. The peer leaders were sent these videos along with the manuals via email. After they watched each video and reviewed the materials, 1- to 1.5-hour-long “refresher” trainings occurred every week beginning on June 13, 2019, via Zoom (the online platform that was used for the actual intervention groups). During the refresher trainings, led by Drs Cook, Ellis, and Simiola, peers discussed the session video and manual sent to them 1 week prior and were encouraged to ask questions and provide feedback and reflections. Concerns and issues were navigated and addressed. At the request of peers, some in vivo role playing took place to practice MI concepts. Based on feedback from peers, user-friendly changes were made to the training manuals and other materials (eg, in-session activities). The investigative team was in regular contact with the peer leaders from the start of their enrollment of participants in the project. We offered weekly conversations and email exchanges and continually reminded them that we were willing and available to speak over the phone whenever needed. Importantly, we routinely solicited peers' input on various aspects of the project and incorporated feedback in meaningful ways, contributing to their sense of being valued members of the team. In addition, we created step-by-step, user-friendly Zoom guides tailored for peer leaders and group participants, respectively, to introduce them to and facilitate their comfort with using this technology for online group sessions. These guides illustrated how to download and sign in to Zoom and how to use various Zoom features (eg, raise a hand, send chat messages to the group, mute and unmute microphone, toggle between speaker and gallery view, share a screen) and detailed important considerations to keep in mind when joining a Zoom meeting. We consulted with colleagues with experience and expertise in tele-mental health to develop some of these points (eg, importance of joining a Zoom session from a private room to protect the confidentiality of the group; not engaging in other activities, such as driving or eating, during a session). These guides could be used as future resources for clinicians, researchers, and community partners running tele-mental health groups or conducting clinical research. We created several other resources for the peers, including a Frequently Asked Question document that answered concerns about leading groups, engaging study participants, dealing with participant emotional distress, and navigating misgendering of participants (ie, use of incorrect pronouns). A notes template was also provided to the peers to use as they conducted sessions to help them remember information that is shared with them (eg, participants' chosen goals to work on). After the first year, we began recruiting additional peer leader candidates to enhance our current cohort of peers. Given his extensive network and access to peers in his own organization, we asked Mr Struve, executive director of MenHealing, for personal recommendations and referrals of other suitable peer leader candidates. We also asked MaleSurvivor for additional peer leader recommendations and were able to follow up with several interested people from the previous year who were unable to attend the in-person training. In addition, we asked our current peer leaders and advisory board members for recommendations. Drs Cook and Ellis interviewed additional peer leader candidates over Zoom to gauge the candidates' comfort with and ability to use this technology. We used the same format to interview potential peers as described earlier. We recruited 14 potential peer leaders for a year 2 cohort, of whom 12 attended the Zoom training and were randomly assigned to an intervention condition. Three recruited peer leaders dropped out before attending any training because of COVID-19-related issues. In addition, 2 peer leaders dropped out after randomization. Starting in April 2020, the year 2 cohort was invited to attend 6 online sessions with the research team. In addition to these 1.5-hour Zoom calls, participants were given access to online videos of the original May 2019 in-person training at Yale. Peers were asked to watch the videos in advance of the online training; online training consisted of reviewing material, answering questions, and role playing. Peer leaders were then randomly assigned to the MI or MI+AC conditions. Because we had our “veteran” peer leaders (ie, peers who were trained in the first year of the project), we paired year 2 peers with year 1 peers to shadow and train in running the groups. Recruitment of SGM Trauma Survivors We created several versions of recruitment flyers by using SGM-affirmative materials targeting different SGM subgroups, such as materials specifically geared toward trans men, gay or bisexual men, men questioning their gender identity or sexual orientation, and men who have sex with men. We developed several recruitment messages to use on social media platforms such as Twitter and Facebook and created a study website (www.peersformenshealthstudy.com; see Appendix A ). In addition to providing information on the study purpose, procedures, answers to frequently asked questions, and links to the informed consent form and online screening survey, the website included information about the research team and advisory board members and provided contact information for participants wanting to speak directly to a member of the research team. The website also included brief informational videos that were created as part of our PCORI Engagement Award #3013, “Facilitating Male Trauma Survivors' Meaningful Involvement in Health Research.” Two videos featured Christopher Anderson, former executive director of MaleSurvivor, discussing how male survivors can participate in research and have their voice be heard as well as challenges faced by male survivors. The third video featured Dr Ellis explaining how trauma disproportionately affects the SGM community. We identified agencies across the United States and Canada with which we had existing connections and others that appeared relevant and promising for recruitment purposes. This list of potential agencies was then reviewed by various members of the investigative team to determine whether there were additional sources to add and contact information for key people at those organizations who might assist with recruitment. Finally, members of the advisory board were asked to review the list and offer additional sources or contacts. We reached out to the agencies and organizations by telephone and email, requesting permission to post information about the project and recruitment materials on their websites and during any events they host (eg, workshops, conferences). These recruitment materials (eg, flyers, study website) were all approved by the Yale Human Investigations Committee. In addition, we posted recruitment notices in the discussion forums hosted by MaleSurvivor. We contacted more than 180 organizations, associations, and professionals across the United States and Canada. Many agreed to disseminate the study materials within their organizations, in newsletters, on listservs, on their social media, and in their extended networks, and in several cases they directed us to additional contacts, enabling us to forge new connections and snowball recruitment efforts. Despite the team's concerted and repeated recruitment efforts, however, participant flow was initially slow. Through connections our PCORI program officers facilitated with fellow SGM researchers, such as Dr Conall O'Cleirigh at the Fenway Institute at Fenway Community Health, we learned how important social media advertisement is to reach this marginalized community. We thus reached out to several agencies that work with SGM dating sites and social media platforms and eventually enlisted the services of Commando Advertising LLC, a company specializing in targeted advertising to SGM communities. Lucas Anemone, CEO of Commando, graciously provided us with a discounted rate for advertising, and his organization conducted targeted advertising of our study via social media platforms (Facebook and Instagram) and SGM dating sites (GROWLr and Grindr). These campaigns generated widespread interest, particularly among eligible participants. Several strategies were used to reduce participant attrition, including following up promptly by phone and email with people who submitted online screening surveys (the same day screeners were received or the next business day), flexibly scheduling phone screening interviews to accommodate potential participants' schedules and time zones, making efforts to schedule groups on the days and times that worked best for most participants, sending twice-weekly reminder emails to participants about upcoming group sessions, and following up with participants when they missed a session to make sure that they received the information needed to join the groups, including the correct date and time. Finally, to facilitate retention, we gave participants $20 for completing each of the 4 assessments (ie, baseline, postintervention, 60-day follow-up, and 120-day follow-up), for a total possible amount of $80. Screening and Inclusion Criteria for Study Participants Note: The material presented in this section previously appeared in the following peer-reviewed publication: Ellis AE, Martino S, Simiola V, Mackintosh MA, Bellamy C, Cook JM. Study design and interventions for a peer-delivered motivational interviewing group treatment for sexual and gender minority male sexual trauma survivors. Contemp Clin Trials. 2021;111:106597. doi:10.1016/j.cct.2021.106597 [ PubMed : 34653650 ] [ CrossRef ] Interested participants were directed to the study website containing informed consent, frequently asked questions about participation, and a screen for eligibility. The short eligibility for the trial screen asked participants' sociodemographic status, history of sexual abuse or assault, depressive symptoms, and past 60-day formal mental health treatment. Because gender identity is a self-defined construct and this study was focused on SGM men, to be eligible, participants needed to self-identify in at least 1 of these categories: cisgender male individuals who identify as gay, bisexual, queer, or questioning; cisgender male individuals who report having sex with men; participants who identify as transgender; or participants who identify on the transmasculine spectrum. Eligibility criteria also included being 18 years of age or older; speaking English; living in the United States or Canada; reporting a history of sexual abuse across their lifespan; having a minimum cutoff score of 16 on the Center for Epidemiologic Studies Depression Scale (CES-D) 51 ; and having not participated in formal mental health treatment in the past 60 days. Because some participants may not label their unwanted sexual experiences as traumatic, 52 may minimize or underreport emotional distress, 36 or may be uncomfortable disclosing their SGM identity, 53 research staff followed up via telephone with participants who scored between 10 and 16 on the CES-D, denied any history of sexual trauma, or indicated that they were cisgender and heterosexual to confirm study exclusion. Of those deemed eligible, participants were contacted by a study team member to set up a time for a phone screen. During the telephone screen, team members reviewed the informed consent process verbally, noting participants' ability to withdraw from the study at any time without penalty. Several modules from the Mini-International Neuropsychiatric Interview 54 (ie, depression, PTSD, generalized anxiety, alcohol and drug use, psychosis) were administered to assist in determining eligibility. The Columbia-Suicide Severity Rating Scale (C-SSRS) 55 was used to identify those who have high suicidal lethality and need appropriate intervention (eg, referral to health care professionals in their area, emergency intervention). The Telephone-Assessed Mental State 56 was also administered to screen for cognitive impairment. Once potential participants' safety was assured, those who met other study eligibility criteria were invited to participate in the study. To increase generalizability, exclusion criteria were limited to the following: active psychosis (in the past 3 months), severe suicidal ideation with intent, or cognitive impairment. Other exclusion criteria included no access to a computer or smartphone, moderate to severe hearing or speech impediment that might prevent engagement in the online intervention, and engagement in formal mental health treatment in the past 60 days (ie, those who endorsed having at least 1 visit or scheduled appointments to any mental health services in the past 2-months were considered to have initiated treatment [eg, psychiatrist, psychologist, social worker, psychiatric nurse]). Reasons for Declining Participation In the first cohort of peers, 4 did not attend the in-person training. One was referred to serve on the advisory board, 1 indicated he was no longer interested, 1 stopped responding to the study team, and 1 could not attend the training because of scheduling conflicts. After the in-person training, 5 additional peers withdrew from the study. Two peers enrolled in school to continue their education and were no longer able to commit to the project, and 3 had competing time demands that precluded them from running groups. In our second cohort of peer leaders, 3 recruits dropped out before attending any training because of COVID-19 related issues and 3 more dropped out after randomization, 2 of whom indicated that the timing was not a good fit for their current phase of recovery and the other who cited competing time demands. Eligible trial participants were asked to provide a reason for declining participation whenever possible. Typically, this was facilitated by the project manager reaching out to a participant who indicated they were no longer able to join the study and asking them for potential reasons. In total, 125 eligible participants (approximately 10%) who consented to participate declined to enroll in the trial. Of these, 83 reported they were no longer interested, 18 had scheduling conflicts, 3 cited family or personal issues, 6 had concerns about privacy, 13 anticipated the content to be too distressing, and 3 did not provide a reason. Of note, these categories were not mutually exclusive, and some participants cited more than 1 reason. One participant was withdrawn by study staff after disclosing that he completed the online and telephone screenings representing someone else' experience as his own. Interventions and Comparators or Controls Motivational interviewing was compared with MI+AC. Groups took place entirely online via video teleconferencing software. Groups met for 1.5 hours once a week for 6 weeks, and each was led by 2 trained peers. Four to 10 participant members were enrolled in each group. Motivational Interviewing Note: The material presented in this section previously appeared in the following peer-reviewed publication: Ellis AE, Martino S, Simiola V, Mackintosh MA, Bellamy C, Cook JM. Study design and interventions for a peer-delivered motivational interviewing group treatment for sexual and gender minority male sexual trauma survivors. Contemp Clin Trials. 2021;111:106597. doi:10.1016/j.cct.2021.106597 [ PubMed : 34653650 ] [ CrossRef ] The MI group followed traditional principles in which the peer leaders blended fundamental patient-centered counseling techniques (eg, reflective listening) with technical methods (eg, develop discrepancies between important life goals and current behavior) to elicit participant statements that favor change and diminish those that argue against change. 31 , 32 The nonjudgmental, nonauthoritarian style and emphasis on acceptance, compassion, and respect for and empathic understanding of the participants' experience was seen as ideal for SGM masculine-identifying survivors, whose experiences of stigmatization and mistrust might challenge the peer leaders' ability to engage them in a group intervention. The 6 sessions ( Table 1 ) covered the following topics: (1) exploring current life stressors or problems and relationships to trauma, (2) targeting trauma-related behavioral change, (3) decisional balance for making changes, (4) exploring personal values and strengths, (5) building self-efficacy, and (6) readiness to change and change planning. Peer leaders listened for opportunities in each session to motivate trauma-related behavior change (eg, identify reasons for change) and encourage engagement in formal mental health services. Table 1 MI and MI+AC Session Topics and Objectives. Motivational Interviewing and Affirmative Care Note: The material presented in this section previously appeared in the following peer-reviewed publication: Ellis AE, Martino S, Simiola V, Mackintosh MA, Bellamy C, Cook JM. Study design and interventions for a peer-delivered motivational interviewing group treatment for sexual and gender minority male sexual trauma survivors. Contemp Clin Trials. 2021;111:106597. doi:10.1016/j.cct.2021.106597 [ PubMed : 34653650 ] [ CrossRef ] The MI+AC method integrates AC content into MI. Although a formal pilot study testing the initial efficacy of this condition was not conducted, this comparative effectiveness trial builds on findings from a PCORI-funded Eugene Washington Engagement Award, titled “Facilitating Male Trauma Survivors' Meaningful Involvement in Health Research.” 57 Together with our nonprofit community partners, MaleSurvivor and MenHealing, we tailored MI with trauma-informed, SGM-affirming care to encourage formal engagement in mental health treatment for SGM male sexual abuse survivors. This content was developed by reviewing existing interventions and programs specific to SGM minority stress, 58 , 59 traditional masculinity and help seeking, myths about sexual abuse of men, and exploration of masculinity and sexual orientation in the context of interpersonal sexual assault, all to be consistent with AC practice. 59 Affirmative care generally refers to culturally aware, tailored, and informed treatment for SGM people. Two primary approaches are detailed in the literature: a stigma-informed approach and a minority-stress approach. Given the increased risk for traumatization within SGM populations, AC approaches care by reducing internal biases and stigma and providing education around minority stressors and traumas. This includes acknowledging the big and small discriminations that members of the SGM community face (eg, insults, hate crimes, marriage restrictions). Interventions typically used include building coping skills, fostering community and social support, and changing unhelpful thoughts 59 (eg, changing “Because of my sexual orientation or gender identity, I feel excluded from society” to “There are some people and institutions in today's society who will not accept me because of my sexual orientation or gender identity, but there are plenty of people and places that will welcome and accept me. I can find and build my own supportive community over time.”). Affirmative care content was drawn from the American Psychological Association Guidelines for Psychological Practice With Transgender and Gender Nonconforming People, 60 American Psychological Association Guidelines for Psychological Practice With Lesbian, Gay, and Bisexual Clients, 61 and other guidelines for SGM-affirmative mental health practice. The MI+AC content integrates 6 key components targeted for gay and bisexual men 45 : validating the potential emotional distress that comes from being a member of a minority group; reworking negative cognitions stemming from early and ongoing minority stress experiences; empowering SGM men to communicate openly and assertively across contexts; validating SGM men's unique strengths; affirming healthy, rewarding expressions of sexuality; and facilitating supportive relationships. The MI+AC condition operated under the assumption that men are influenced by traditional masculinity gender norms in seeking help for mental health distress (M. E. Addis, unpublished manuscript, 2012). 48 For example, traditional ways in which boys and men are socialized is intricately tied to male rape myths (eg, ”men who are raped by men are gay”). 62 During MI+AC group sessions, myths and facts were presented about sexual abuse in men, sexual abuse in SGM people, and men seeking mental health treatment. Using an MI style, peer leaders discussed maladaptive thoughts related to these topics, provided psychoeducation, and helped replace negative, unhelpful, or distorted thoughts (about sexual trauma in men, about being a member of an SGM group, about having been sexually victimized as an SGM) with more helpful or accurate thoughts, all practices consistent with SGM-affirmative 63-65 and trauma-informed care. 66 See Table 1 for AC additions made to each MI session. Before the trial, acceptability and feasibility were ensured through the formation of an advisory board with expertise about SGM health, male survivors, and intervention development that formally reviewed and revised materials for the MI+AC sessions. Study Outcomes Aim 1 Measures Train peer leaders to deliver MI and MI+AC in online groups with integrity and distinction based on the AC content. Demographics and previous mental health treatment and peer leader training experiences Participants were asked to provide their age, gender, sex assigned at birth, sexual orientation, race, ethnicity, marital status, educational attainment level, and work status. Peers were also asked about prior receipt of mental health services and formal mental health or peer leader training. Beliefs about MI. 67 Peers completed a scale rating their beliefs about MI, adapted from a similar instrument surveying beliefs about empirically supported treatments. They indicated their agreement or disagreement with statements about their beliefs about 6 items describing MI's effectiveness (eg, ”MI is or would be effective with masculine-identifying trauma survivors”) and their own personal familiarity with the intervention. A total score was created, with higher scores indicating stronger positive beliefs about MI (range 6 to 30). Self-reported learning of MI skills Peers completed a postevaluation survey both after the 3-day workshop and at the end of the study. The 10 questions, developed for this study, centered on the extent to which peers learned the area described in each item as a result of the workshop. Sample items included “To what extent did you learn how to focus on a target behavior as a precondition for enhancing motivation for change?” Response options included “not at all,” “very little,” “a little,” “somewhat,” “quite a bit,” “considerably,” and “extensively.” Total scores were created for each time point, with higher scores indicating more self-reported learning (range, 7-70). Workshop feedback Two open-ended questions asked about the best aspects of the in-person training and how the training could be improved. The Independent Tape Rater Scale. 68 The Independent Tape Rater Scale (ITRS) was used to monitor adherence to and competence in delivering both MI interventions. The ITRS includes items that cover therapeutic strategies that are MI consistent (eg, reflections) or inconsistent (eg, unsolicited advice). For this trial, we added 4 items that detailed key aspects of trauma-informed, SGM-affirming care: (1) psychoeducation about sexual trauma, minority stress, and masculinity or how to manage or cope; (2) exploration of negative cognitions related to male sexual abuse, sexual and gender minorities, minority stress, and men seeking mental health support; (3) AC style or spirit; and (4) facilitating supportive relationships. Three items were added to capture other prescribed (sharing lived experience; orientation to group guidelines, content, materials, and activities) and proscribed behaviors (informal discussion and self-disclosure). For each MI-consistent, AC, and other prescribed item, independent raters (ie, female research associates within the Department of Psychiatry at Yale who had been previous raters of MI in other MI studies by Dr Martino) listened to audio recordings of a sample of both MI conditions and evaluated the peers for adherence (ie, extent of intervention delivery) and competence (ie, skill or quality of intervention delivery) by using 7-point Likert scales. MI-inconsistent or proscribed items were rated only for adherence. We calculated mean adherence and competence scores for the 2 factors (fundamental and advanced MI strategies) identified in prior psychometric analyses 69 as well as for the AC items and examined the frequency of MI inconsistencies in the sessions. Our investigative team had documented experience training ITRS raters to perform reliable ITRS session process ratings in previous trials. 70 Aim 2 Measures Determine the comparative effectiveness of MI and MI+AC on 2 primary outcomes (depression and mental health treatment engagement). Note: The material presented in this section previously appeared in the following peer-reviewed publication: Ellis AE, Martino S, Simiola V, Mackintosh MA, Bellamy C, Cook JM. Study design and interventions for a peer-delivered motivational interviewing group treatment for sexual and gender minority male sexual trauma survivors. Contemp Clin Trials. 2021;111:106597. doi:10.1016/j.cct.2021.106597 [ PubMed : 34653650 ] [ CrossRef ] Specific information related to the measures administered at each time point is provided below. Initial online screening measures Participants were asked demographic information about their age, assigned sex at birth, gender identity, race, ethnicity, sexual orientation, marital status, highest level of education, and employment status. Participants were also asked for pronouns and preferred name. Participants were asked whether they had any unwanted sexual experiences in childhood (“yes,” “no,” or “don't know”). If participants indicated that they had any unwanted sexual experiences, they were then asked how many individuals or groups of people committed these unwanted acts before their 18th birthday. Participants were asked to indicate how many times they experienced these unwanted acts (ie, ”single incident,” “2 to 10 incidents,” 11 to 20,” and so on). The same questions were asked about unwanted sexual experiences in adulthood (whether they had experienced any unwanted acts, how many people committed these acts, and the number of acts committed after their 18th birthday). Additionally, participants were asked whether adult sexual assault was the result of military sexual trauma (“yes” or “no”). In addition, the following measures were administered at online screening. The CES-D 47 is a 20-item measure that asks about the experience and frequency of depressive symptoms over the past week. A score of 16 or higher typically identifies people at risk for major depression. This score was used as the cutoff for inclusion in the study. The CES-D has high reliability (0.84 to 0.90) and test-retest reliability (0.67). 47 The Life Events Checklist for DSM-5 71 screens for exposure to 16 potentially traumatic events across a person's lifetime. Participants were asked to indicate whether the event happened to them personally, they witnessed it happen to someone else, they learned about it happening to someone close to them, or it did not apply to them. A brief modified version of the Service Use and Resource Form 7 2 was used to assess past 60-day engagement with a mental health professional (eg, psychiatrist, psychiatric nurse, social worker, counselor, psychologist). If participants endorsed seeing 1 of these professionals, they were then asked to indicate how many times over the past 60 days. Phone screening measures The Mini-International Neuropsychiatric Interview 49 is a structured interview that took approximately 15 to 20 minutes to administer. It was used extensively to make quick, accurate diagnoses of psychiatric disorders. The following modules were used in this study: Major Depressive Episode, Suicidality, PTSD, Alcohol Use Disorder, Substance Use Disorder, Psychotic Disorders, and Generalized Anxiety Disorder. The Telephone-Assessed Mental State 51 is a brief measure used to screen for cognitive impairment. It includes 4 items from the widely used Mini-Mental State Examination to assess orientation to time and place, attention, and memory. The C-SSRS 50 is a frequently used measure of suicidality. High scores alerted the investigative team to conduct a risk assessment, identify a need for mental health resources, and make a final eligibility determination. This measure has good convergent and divergent validity with other multi-informant suicidal ideation and behavior scales and high sensitivity and specificity for suicidal behavior classifications, and it is sensitive to change over time. Primary outcomes Primary outcomes were (1) depression, as measured by the continuous score on the CES-D administered at baseline, postintervention, and 60- and 120-day follow-ups, and (2) mental health treatment engagement, the binary distinction between those who initiate or reinitiate mental health treatment and those who do not. Mental health treatment engagement is operationalized as having 1 or more visits or scheduled appointments to any mental health services within 120 days of the last online group, as described by Seal et al. 34 Secondary outcomes The PTSD Checklist for DSM-5 73 is a 20-item measure that corresponds to the diagnostic criteria for PTSD. Participants indicate the extent to which they have experienced each symptom in the past month on a 5-point scale, from 1 (“not at all”) to 5 (“very often”). This instrument has demonstrated good reliability and validity. 74 The Alcohol, Smoking and Substance Involvement Screening Test 75 is an 8-item measure of use of alcohol, tobacco products, and other drugs across the lifespan and in the past 3 months. The test has been shown to be a valid indicator of active substance use with adequate construct validity. The Brief Inventory of Psychosocial Functioning 76 is a 7-item scale that assesses functional impairment or quality of life related to trauma and PTSD. Response options range from 0 (“not at all”) to 6 (“very much”) and assess functioning in relationships, work, socializing, parenting, education, and self-care. The inventory has high internal consistency and adequate test-retest reliability. 77 The Service Use and Resource Form 72 assesses the use of inpatient and outpatient mental health services in the past 60 days, psychotropic medication use, general health, and the use of outpatient medical and surgical treatment services in the past 90 days. The C-SSRS 50 was described earlier. The Brief Dissociative Experiences Scale Modified for DSM-5 78 is an 8-item measure that assesses the severity of dissociative experiences. These include feeling detached from oneself, feeling that one is watching oneself do something and seeing self as if looking at another person, and finding evidence of having done things one does not remember doing. Higher scores indicate greater severity. The scale is highly correlated with the longer Dissociative Experiences Scale-Revised. 79 Participants are asked to rate the severity of their dissociative experiences during the past 7 days. Covariates Note: The material presented in this section previously appeared in the following peer-reviewed publication: Ellis AE, Martino S, Simiola V, Mackintosh MA, Bellamy C, Cook JM. Study design and interventions for a peer-delivered motivational interviewing group treatment for sexual and gender minority male sexual trauma survivors. Contemp Clin Trials. 2021;111:106597. doi:10.1016/j.cct.2021.106597 [ PubMed : 34653650 ] [ CrossRef ] The Barriers to Help Seeking Scale 80 is a 31-item scale that assesses several barriers to help seeking (eg, need for control and self-reliance, minimizing problem and resignation, concrete barriers, distrust). The scale has good internal consistency, convergent validity, and criterion validity. The Conformity to Masculine Norms Inventory 81 assesses conformity to traditional masculine norms over 9 subscales: winning, emotional control, primacy of work, risk taking, violence, heterosexual self-presentation, sexual activity, self-reliance, and power over women. Subscale internal consistencies are high. The Minority Stress Scale 82 is a 43-item questionnaire that assesses experiences of stigmatization, discrimination, and internalized homophobia because of sexual orientation. It is based on Meyer's minority stress theory 83 and has shown good internal reliability and good convergent validity. 82 Aim 3 Measures Examine SGM trauma survivors' past mental health treatment experiences, perspectives on peer-led MI interventions, and preferences for future mental health treatment. Mental health treatment needs, preferences, and experiences Within 4 months of the conclusion of the intervention, all participants randomly assigned to a condition were invited to participate in a telephone interview about their experiences with, and preferences for, mental health services (eg, psychotherapy, pharmacotherapy, in-person vs telehealth, group or individual format, and delivery by a peer vs a licensed professional). In addition, participants were asked to provide feedback related to the peer-led groups conducted as part of the larger study, including what they liked most and least, their expectations and goals, and the acceptability of the virtual format. A grounded theory approach was used to guide qualitative analyses of the responses. Sample Size Calculations and Power Because this study examined repeated-measures outcomes with the 2 conditions, assigned at the individual level, power analysis made several assumptions: continuous outcomes (eg, depressive symptoms as the primary outcome and other mental health symptoms as secondary outcomes), a linear link function, random effects covariance structure, and homogeneous covariance structure (within treatment groups). In a recent meta-analysis of e-health interventions on depression and anxiety, small to medium effect sizes were observed for the direct relationship between e-health interventions and depression and anxiety at postintervention and at 6- and 12-month follow-up (ranging from d = 0.21 to d = 0.42). 84 Based on this information, we conservatively assumed an effect size of d = 0.35, with a power of .80 and an α of .05; 137 participants per group would be needed. This represents a total completed sample of 274. Assuming a dropout rate of 20% (rounded up to 70 participants, for nearest multiple of 2), this required a minimum recruited sample of at least 344. In a meta-analysis of 72 clinical trials, the initial effect size (ie, 1 month postintervention) was quite high ( d = 0.77). The strength of the effect decreased over time, however, with effect sizes of 0.39 at 1 to 3 months and 0.31 at 6 to 12 months. 84 Time Frame for the Study The intervention period extended over six 1.5-hour sessions, which were primarily conducted weekly with the exception of a few occasions where group sessions were delivered every other week because of holidays or other exceptional circumstances. Group sessions were never conducted more than 1 time per week. The start dates for the groups were staggered in cohorts. Participants were randomly assigned after a cohort (eg, 16 participants) completed the baseline measure. The first group meeting took place within 7 days from the date of randomization. The follow-up period extended over 4 months, with assessment intervals immediately posttreatment and at 60- and 120-day follow-up. The follow-up periods were chosen according to the Seal et al. 34 trial. Although a call for action was published in 2014, 85 there has been limited consensus and movement in the field to develop evidence-based guidelines for follow-up intervals of depression. Therefore, we chose to use the intervals set by Seal et al. to allow for a more accurate comparison of findings. Data Collection and Sources Prospective data were collected online from secure databases hosted through PsychData.com, Qualtrics, and Research Electronic Data Capture (REDCap). Information about recruitment of prospective participants is provided above (see “ Recruitment of SGM Trauma Survivors ” section). Participants were sent up to 3 personalized email reminders to complete each online assessment. Reminders were automated through the REDCap database and were sent at 3-day intervals. Throughout the project period, the study staff worked diligently to build rapport with participants, offering them assistance with finding referrals for mental health professionals in their area, upon request. Genuine positive regard, authenticity, openness, and active listening were the most effective strategies for working and retaining peers, study participants, and other stakeholders. As clinical psychologists, the project staff were trained throughout their graduate education and subsequent careers to use this approach in building trust, rapport, and transparency. The project team worked to dismantle a hierarchy between the investigative team, study patients, and stakeholders. That is, we emphasized collaborative, bidirectional, and personal relationships with each of our peer leaders that allowed us to be supportive of them, as this was challenging work (in terms of both content and COVID-19-related life stressors) at times. PCORI prohibits financial remuneration for study interventions, and thus a small token of appreciation was given in the amount of $60 gift cards to each peer for each 6 weeks of group run. Furthermore, we approached this in the same manner when working with study participants. If a participant contacted the study staff to request withdrawal from the study, the project manager followed up to ask the reason, which, when provided, was documented in an internal tracking database. Participants were deemed lost to follow-up only if they did not complete all 3 follow-up assessment measures (ie, immediately posttreatment and at 60 and 120 days). Analytical and Statistical Approaches Preliminary Analysis As a preliminary step, to assess the success of randomization, baseline demographics, and clinical characteristics, including gender identity, we compared the 2 randomly assigned groups using χ 2 tests for categorical variables and t tests or Mann-Whitney tests for continuous variables. Descriptive statistics and graphical displays are used here to describe the sample, primary and secondary outcomes, and proposed moderating and mediating variables. Data analyses were conducted on the intent-to-treat sample. All variables were evaluated for their distributional properties and data processing errors. Robust estimators were used to address nonnormal data. All participants were followed and included in the statistical analyses regardless of their retention in treatment. Missing Data Assessment All variables were assessed for the amount and pattern of missing data. For primary outcomes, analyses were conducted assessing the relationship between missingness patterns and treatment group, secondary outcomes, and sociodemographic characteristics. It was determined that data were missing at random. Restricted maximum likelihood estimation was used in subsequent linear mixed-model (LMM) analyses to address missingness. Analyses were conducted in SPSS, version 28.0, statistical software (IBM Corp). 86 Assessment of Treatment Integrity of Peers Running MI and MI+AC Groups We measured the degree to which peer leaders delivered MI and MI+AC sessions with integrity by examining the independent ITRS item ratings across a random sample of sessions in both conditions, ensuring the inclusion of all peers delivering the interventions. Descriptive statistics were used to determine the degree to which the sessions met a criterion level for adequately performed MI—namely, at least half the MI consistent items rated average or above for both adherence and competence. 70 Mixed models, controlling for measures nested within time and peers, were used to determine whether AC items occurred with higher adherence and competence in MI+AC than MI only, as intended. We determined whether MI components were carried out equally across the 2 groups. Assessing Difference Between Treatment Conditions For outcome analyses, LMMs of mental health symptoms were modeled as a repeated-measures outcome variable, nested within participants, via LMM analyses. Significant between-group differences on baseline demographic and clinical variables were included as time-invariant covariates (between participants), as was treatment group. These data were nested within cohorts (as a random effect) in the model. Thus, for each mental health symptom outcome, the primary analysis included all randomly assigned participants in the analyses, nested within cohorts, and controlling for baseline clinical and demographic variables. Generalized estimating equations were used to assess effects of treatment conditions on categorical outcome variables. Assessment of Potential Mediators Before examining the potential role of any mediators on the relationship between condition and depression, we conducted LMM analyses to identify any main or interaction effects condition or time had on these mediators as outcomes. If the effects were significant, we conducted single-mediation and multiple-mediation analyses via the SPSS PROCESS module. All significant single mediators were then included in a multiple-mediator model for examination of full effects. Evaluation of Heterogeneity of Treatment Effects Inclusion of demographic and clinical variables in mixed models allowed testing of heterogeneity of treatment effects, with adjusted P values. Specifically, in addition to the primary analyses, subsequent supplementary analyses tested for the effects of treatment group × demographic interactions (eg, race, comorbidity, and education) because these are the most likely candidates for heterogeneity of treatment effects. The planned analyses examined all baseline demographic and clinical variables as potential moderators of outcomes. Qualitative Interviews Assessing SGM Male Survivors' Mental Health Needs and Treatment Preferences To examine SGM male survivors' mental health needs and preferences for treatment and experiences in groups, we invited participants who were randomly assigned to participate in a 1-time telephone interview. A qualitative codebook to identify themes was created. We used grounded theory method, whereby interview transcripts were subjected to line-by-line, open coding. Codes were generated inductively (ie, in a bottom-up fashion) such that they are grounded in the data. Using the constant comparative method, 87 we compared coded segments to each other to develop and refine concepts and their properties. Changes to the Original Study Protocol There were minor changes to the study plan described in the funded PCORI application. First, we dropped several questions about participants' experiences of sexual abuse (eg, whether SGM male survivors knew the perpetrator of their sexual abuse or assault, whether sexual penetration was involved) to reduce potential participant distress. Second, we increased the total number of participants enrolled from 344 to 356. This occurred because more participants completed the online screener, were eligible, and expressed interest in participating than our recruitment target. We believed it was unethical to deny these participants the right to engage in the groups and therefore continued to randomly assign participants until the eligibility pool was completed. Finally, we also added a measure of dissociation that was used in the moderator analyses. This was added after Drs Cook and Ellis, who were conducting the phone screens, identified a pattern of participants describing significant dissociation when asked about psychotic symptoms. The investigative team agreed that having a formal measure of dissociation would improve the understanding of participant characteristics that might affect project outcomes. Results Overview of Participant Flow Through the Study Interventions A total of 356 participants were randomly assigned to 1 of 2 interventions, with equal numbers in each group (n = 178 each). A detailed breakdown of participant dropout rates is provided in the CONSORT diagram in Figure 2 . Figure 2 Flow Diagram of Participant Enrollment. Of the initial 178 MI-only participants, 42 (24%) were lost to follow-up at the postintervention assessment period vs 31 (17%) of the initial 178 MI+AC participants. At the 60-day postintervention observation, 47 participants in the MI-only group (26%) and 41 participants in the MI+AC group (23%) were lost to follow-up. At the 120-day follow-up period, 55 participants in the MI-only group (31%) and 49 participants in the MI+AC group (28%) were lost to follow-up. There were no significant differences in terms of demographic characteristics between those who completed all interviews and those lost to follow-up. Participants lost to follow-up did, at baseline, report significantly higher PTSD symptoms, more dissociative experiences, less resiliency, greater barriers to help seeking, higher levels of minority stress, and higher levels of depression than those who were not lost to follow-up, however. Baseline Characteristics The sample included 356 adults randomly assigned to MI or MI+AC. Across the conditions, participants were an average age of 35 years (95% CI, 33.6-36.1), most identified as cisgender (n = 294 [82.6%]), and 17.4% identified on the transmasculine spectrum (n = 62). The majority were White (85.4%), followed by Latino (14.6%) and Black/African American (9%). Sixty-six percent identified as gay, and 21.7% identified as bisexual. Participants were most likely to be single (60.4%) or in a long-term relationship (17.1%). Most had a bachelor's degree (27.3%) or some college education (28.7%). Forty-seven percent were employed full time, and another 10.4% were employed part time. Fourteen percent were unemployed and looking for work. Sixty-seven percent reported making less than $50 000 a year. Six percent reported being currently in the military, and 8% reported ever being in the military. The majority (88.8%) were not mental health treatment naive (meaning they had received mental health treatment in their past). There were no statistically significant differences between MI and MI+AC groups in terms of baseline demographics or participation in the intervention. See Table 2 for a full description of baseline demographic characteristics. Table 2 Demographic Characteristics (N = 356). Baseline Differences in Outcomes Table 3 contains the average scores and 95% CIs for participants in the 2 conditions on primary and secondary outcomes and covariates. The only significant between-group difference at baseline was that participants assigned to MI+AC had significantly lower scores on the Minority Stress Scale subscale sexual orientation concealment. Table 3 Baseline Scores on Primary and Secondary Outcomes and Potential Mediators. At baseline, 91.2% of the full sample met the criteria for severe depression, with no significant differences between groups; 49.5% of participants were considered at moderate risk of suicide and 9% were at high-risk of suicide, according to C-SSRS scores, without intent. Group Participation Overall, 79% of participants attended the online groups, attending an average of 3.4 sessions across the sample. There were no significant differences between participants in MI and MI+AC in terms of the proportion of who attended any group or the number of sessions attended ( Table 4 ). Table 4 Group Characteristics. Primary Outcomes Aim 1 Train peer leaders to deliver MI and MI+AC in online groups with integrity and distinction based on the AC content. Peers ranged in age from 26 to 66 years (mean [SD] = 49.25 [11.22] years). All identified as men and reported that their assigned sex at birth was male. Half of the peers self-identified as sexual minorities (n = 18), and the remaining identified as heterosexual or straight. The majority were White (88%). Forty-one percent of the peers earned advanced graduate education, and 78% were employed at least part time. The majority reported that they had received formal psychotherapy in the past (97%), and 31% reported they had received previous formal mental health or peer leader training. Thirty-two peers attended the initial training. Twenty-six peers attended the additional booster sessions aimed at supplementing their initial foundational training. On average, peers attended 4.73 booster sessions of a possible total of 6. There was no crossover in peers (ie, no peer was trained for 1 study arm but led group for the other study arm). For the MI condition, which hosted four 90-minute trainings, peers attended on average 3.42 sessions (at least 86% of the offered training). For the MI+AC condition, which hosted six 90-minute trainings, peers attended on average 4.25 sessions (at least 71% of the offered training). A total of 25 MI and 25 MI+AC groups were conducted over the course of the trial. Twelve of 13 peers (92%) trained in MI facilitated sessions. Eleven of 13 peers (85%) trained in MI+AC facilitated sessions. Assessment of treatment integrity for MI and MI+AC groups Overall, MI and MI+AC averaged in the adequate to very good range of adherence to and competence in fundamental MI principles on the ITRS. Observed MI-only sessions were rated significantly higher on advanced MI adherence than the MI+AC sessions, and MI+AC sessions were rated as significantly higher on fundamental MI competence. In terms of AC, the MI+AC sessions observed were rated as significantly higher in adherence to AC principles; however, MI+AC sessions were rated significantly lower in terms of AC competence than the MI-only sessions ( Table 5 ). Table 5 Mean ITRS Fundamental MI, Advanced MI, and AC Adherence and Competence Across Conditions (N = 36 Sessions, 36 Ratings) . Beliefs about MI A 1-way analysis of variance comparing the 3 time points (before training, after the initial training, and after the online booster trainings) on MI beliefs was significant: F (2, 30) = 27.49, P < .001. Post hoc comparison tests with a Bonferroni adjustment indicated that the posttraining (mean [SD] = 17.88 [1.82]; P < .001) and booster training (mean [SD] = 18.81 [1.28]; P < .001) scores were significantly higher than the pretraining (mean [SD] = 15.25 [2.27]) scores, suggesting that positive beliefs about MI increased with additional training. Learning of MI skills Peers answered questions on the extent to which they learned core MI skills. After the initial training, peer leaders' self-assessed MI skill scores ranged from 39 to 70, with an average (SD) of 53.26 (7.66). After the additional 6 booster trainings, self-reported MI skill scores ranged from 50 to 70, with an average (SD) of 60.29 (5.64). This difference was statistically significant, t (15) = 3.63, P = .002, suggesting that the peers felt their MI skills increased with additional training. Aim 2 Determine the comparative effectiveness of MI and MI+AC on 2 primary outcomes (depression and mental health treatment engagement). Analysis of the impact of treatment condition on primary and secondary outcomes (aim 2) was conducted by LMM analyses and included covariates identified as statistically significant between-group demographic and outcome variables identified in Table 1 and Table 2 (ie, scores on sexual orientation concealment of the Minority Stress Scale), along with a baseline value of the dependent variable in the model. Depression There were no significant main effects for condition or condition × time interaction effects on CES-D total depression scores or subscale scores. When we examined the proportion of participants in each condition who fell into the “severe depression” category across time, a significant time × condition interaction was found: A greater proportion of MI+AC participants, compared with MI only, experienced a reduction in depressive symptoms so that they no longer qualified as being at “high risk for severe depression” at follow-up periods. After the intervention, 26.8% of MI+AC participants no longer qualified, compared with 14.2% of MI only, χ 2 (2) = 6.99, P = .03. At the 60-day follow-up, 24.3% of the MI+AC sample no longer qualified for “high risk of severe depression,” compared with 10.9% of MI, χ 2 (2) = 8.04, P = .018. At the 120-day follow-up, 26.8% of MI+AC participants no longer met that criterion, compared with 16.7% of MI (χ 2 (2) = 4.73, P = .112). Across the 2 groups, there was a significant main effect for time, with most experiencing a significant decrease in level of depression symptoms over time ( Figure 3 ). Figure 3 Proportion of Participants With Severe Depression. Mental health treatment engagement There were no significant main effects for condition or interaction effects for initiation of mental health treatment or the number of mental health treatment sessions attended ( Figure 4 , top and bottom). There was a difference in point estimates, however, that was not statistically significant for participants in MI only to attend more mental health appointments at each follow-up period than MI+AC participants ( Figure 4 , top). The proportion of previously treatment-naive patients increased at each time period, regardless of condition ( Table 6 and Table 7 ). Figure 4 Engagement in (Top) and Initiation of Mental Health Treatment (Bottom). Table 6 Linear Mixed Model Analysis of Primary Outcomes (Controlling for Baseline Levels of Sexual Orientation Concealment and Baseline Value of Dependent Variable). Table 7 Estimated Marginal Means and 95% CIs on Primary Outcomes (Adjusted for Baseline Levels of Sexual Orientation Concealment and Baseline Value of Dependent Variable) . Secondary Outcomes Results on secondary outcomes are described below and presented in Table 8 and Table 9 . Table 8 Linear Mixed Model Analysis of Secondary Outcomes (Controlling for Baseline Levels of Sexual Orientation Concealment and Baseline Value of Dependent Variable). Table 9 Estimated Marginal Means and 95% CIs on Secondary Outcomes (Adjusted for Baseline Levels of Sexual Orientation Concealment and Baseline Value of Dependent Variable) . PTSD There were no significant main effects for condition or condition × time interaction effects on the measure of PTSD. Both conditions experienced a significant reduction in PTSD symptoms from baseline to each of the follow-up periods, with the greater decline observed between baseline and 120-day follow-up. There was a nonsignificant difference in point estimates ( P = .08), with MI+AC reporting a greater reduction in PTSD symptoms from baseline to 60-day follow-up than MI only during this same period. Alcohol, Smoking, and Substance Use There was a significant group × time interaction effect on cocaine use, with MI+AC participants reporting a significantly greater decrease in cocaine use from baseline to 60-day follow-up than MI-only participants ( Figure 5 ). Figure 5 ASSIST Scores for Cocaine Use. Psychosocial Functioning There were no significant main effects for condition or time × condition interaction effects on problems with psychosocial functioning. Both groups reported significant decreases in psychosocial functioning problems from baseline to each follow-up period, with the greatest decrease observed from baseline to 60-day follow-up. Suicidality There were no significant between-group differences in suicidality or the proportion of participants who reported no, mild, moderate, or high suicidality. At baseline, 28.8% of the sample reported no suicide symptoms, 12.6% reported mild suicidality, 49.5% reported moderate suicidality, and 9% reported high suicidality. Both groups reported significant reductions in suicidality from baseline to each of the follow-up periods (see Table 8 and Table 9 ). Dissociative Experiences There were no significant differences between conditions in reporting of dissociative experiences, nor was a significant condition × time interaction observed. Both groups reported significant decreases in severity of dissociative experiences over time. Preliminary Examination of Potential Mediators Before examining the potential role of any mediators of the relationship between condition and depression, we conducted LMM analyses to identify the most likely candidates to include in subsequent mediation analyses. Significant findings are briefly presented below, along with figures depicting any significant condition × time interaction effects on the mediator variables, which might indicate the potential for mediation. All detailed results are found in Table 10 and Table 11 . Table 10 Linear Mixed Model Analysis of Potential Mediators (Controlling for Baseline Levels of Sexual Orientation Concealment and Baseline Value of Dependent Variable). Table 11 Estimated Marginal Means and 95% CIs on Potential Mediators (Adjusted for Baseline Levels of Sexual Orientation Concealment and Baseline Value of Dependent Variable) . Barriers to Help Seeking In terms of barriers to help seeking, MI+AC participants reported significantly greater declines in perceived barriers to help seeking over time than MI-only participants. In addition to significant differences on the total score, significant condition × time interactions were found on the Barriers to Help Seeking subscales: need for control and self-reliance, privacy, and minimizing problems and resignation ( Figure 6 ; Table 10 and Table 11 ). Figure 6 Perceived Barriers to Help Seeking: Average Scores and 95% CI. Conformity to Masculine Norms There were significant condition x time interactions on the Conformity to Masculine Norms Inventory scale and 3 of its subscales: self-reliance, power over women, and heterosexual self-presentation. In each case, participants in MI+AC reported significantly greater declines in beliefs that concur with traditional masculine norms. This was especially true for the observation period of baseline to 120 days (for total score, self-reliance, and power over women). For heterosexual self-presentation, the condition × time interaction was significant from baseline to postintervention ( Figure 7 ; Table 10 and Table 11 ). Figure 7 Conformity to Masculine Norms: Average Scores and 95% CI. Minority Stress There were significant condition × time interactions on the overall Minority Stress Scale and the enacted stigma and stigma awareness subscales. On each of the measures, participants in MI+AC reported significantly greater declines in minority stress from baseline to postintervention (total score and enacted stigma) and from baseline to postintervention and baseline to 60-day follow-up (stigma awareness) than participants in MI only ( Figure 8 ; Table 10 and Table 11 ). Figure 8 Minority Stress Scale: Average Scores and 95% CI. Significant Mediators of Depression Outcomes Table 12 contains the significant results identified through the mediation analyses. We examined the degree to which treatment assignment was associated with depression scores and involvement in mental health services via all potential mediators (in separate regression analyses). Results indicate that psychosocial functioning, structural stigma, expectations of discrimination, sexual orientation concealment, and self-reliance (all conformity to masculine norms) independently mediate the relationship between MI+AC and decreased depression scores over time. Thus, MI+AC had a positive and significant impact on lowering overall depression by engaging these mediators (reducing negative beliefs in these areas). Table 12 Significant Mediators of Depression Outcomes. A multivariate mediation model was then conducted in SPSS Process with the inclusion of all 5 of the mediators entered into the model at once. This multiple mediation model identified 3 mediators that, when observed in the presence of independently significant mediators, continued to contribute to a significant indirect effect between MI+AC and reduced depression. These 3 mediators were problems with psychosocial functioning, expectations of discrimination, and self-reliance. That is, MI+AC had a significant indirect effect on reduced CES-D scores by reducing problems with functioning, expectations for discrimination, and beliefs about needing to be self-reliant. There were no significant mediators of the relationship between condition and initiation or engagement in mental health treatment. Heterogeneity of Treatment Effects and Subgroup Analyses To assess heterogeneity of treatment effects, we examined the potential moderating impact that participant demographic variables and significantly correlated covariates had on the relationship between condition and primary outcomes by including a moderator x condition interaction term in our models. We did not find any significant moderators on the relationship between condition and initiation or engagement in mental health treatment. We did find a significant condition × structural stigma interaction, however, such that MI+AC had a significantly greater positive impact on reducing depression among participants with lower levels of structural stigma, while among participants with higher levels of structural stigma, MI+AC was associated with higher depression scores ( Figure 9 ). Figure 9 Moderating Effect of Structural Stigma on Improvement of Depression Outcomes Among Sexual and Gender Minority Participants in MI+AC. Sensitivity Analyses Sensitivity analyses were conducted to determine whether differential findings emerged when we excluded participants with missing data from the overall analyses. The significant findings remained regardless of excluding participants with missing data or using imputed data in LMM. Qualitative Results Aim 3 Examine SGM trauma survivors' past mental health treatment experiences, perspectives on peer-led MI interventions and preferences for future mental health treatment. All participants who were randomly assigned were invited by email to participate in the telephone interview. Interviews ranged from 20 to 45 minutes, with an average length of 30 minutes. A total of 101 responded to recruitment attempts and completed the interview. Most reported they had engaged in some form of mental health treatment during their lifetime, but the majority explained that they had not discussed sexual trauma or related issues. Perceived barriers to engagement included experiences of discrimination, difficulty accessing care (ie, unsure how to find a health care professional, challenges with insurance and finances), or a therapy or therapist style that was not a good fit. Many reported that they had never taken any psychiatric medication and expressed no interest in doing so. Participants identified side effects as the biggest barrier to engaging in pharmacotherapy. Most expressed willingness to seek treatment in the future. The majority who expressed openness to treatment reported a preference for individual therapy. Most noted, however, that they were open to participating in group therapy as an adjunct treatment. When considering from whom they would want to receive treatment, most stated that they would prefer a licensed mental health professional but that they would also appreciate peer support. For additional information on this and the acceptability of the intervention, see Appendix B . Discussion Summary of Results This study helped establish the feasibility and acceptability of training male survivors of sexual trauma to serve as peers in delivering MI. In total, 32 peers were trained to deliver 1 of the 2 interventions, with 23 co-leading at least 1 group over the study course. Peers' feedback related to their experience in the study was overwhelmingly positive. Indeed, peers noted that participation allowed them to reflect on their own recovery as they saw themselves in the participants they helped. Peers also reported that hearing others' struggles helped put their struggles in perspective—both validating and providing context for others' experiences that they may otherwise not have been exposed to (eg, interactions with those of diverse racial and ethnic backgrounds, socioeconomic status, or SGM identity). Many peers noted that talking about their healing with the group participants reduced their own shame and stigmatization and fostered self-reflection and intentionality in continuing their recovery, therapy, or healing. Despite best efforts, the MI and MI+AC conditions may have not been different enough from each other in terms of competence and adherence to distinguish an effect. Both conditions contained substantial amounts of MI-consistent elements performed well (as intended), and both conditions had AC elements done less frequently, though with good skill. The difference in the amount of AC between conditions was statistically significant, but it was still rather infrequent overall. One possible reason for the lack of between-group differences in primary outcomes was that men with lived experience of sexual trauma co-leading both groups with SGM male survivors probably created an atmosphere where trauma was acknowledged and men felt less alone, even if this was not formalized through the use of explicit AC strategies, which occurred more often in MI+AC. Another possibility is that the peers delivered MI well in both conditions, with MI adherence and competence performance comparable to levels achieved in previous MI training trials with a range of health care professionals. 68-70 Mental health symptom and functional improvements and increased treatment initiation may have occurred in part because both groups received good MI that targeted the trial's main outcomes. 32 Perhaps additional attention to providing feedback and coaching in the use of AC strategies during supervision of the MI+AC sessions to make AC more salient beyond the shared experience of the peers with the participants is necessary. Results of this comparative effectiveness trial seem to demonstrate preliminary efficacy for the use of a trauma-informed, peer-led group intervention for SGM male survivors of sexual abuse for reducing depression severity, substance use, PTSD, dissociation, suicidality, and psychosocial impairment and increasing initiation of mental health treatment. The lack of an untreated control group, however, is a problem in claiming that the interventions had an effect. Overall, both groups got better over time and at rates that were not distinguishable statistically for the primary outcome. Using an AC approach appears to improve outcomes for SGM survivors who are experiencing more severe symptoms of depression and also results in a significant decline in minority stress, perceived barriers to help seeking, and traditional masculine norm beliefs. Furthermore, results indicate that psychosocial functioning, structural stigma, expectations of discrimination, sexual orientation concealment, and self-reliance (conformity to masculine norms) independently mediate the relationship between MI+AC and decreased depression scores over time. Thus, MI+AC had a positive and significant impact on lowering overall depression by engaging these mediators (reducing negative beliefs in these areas). Aim 1 Discussion Train peer leaders to deliver MI and MI+AC in online groups with integrity and distinction based on the AC content. Men with lived experience of sexual abuse received training in MI. After the training, participants reported stronger agreement and belief in statements about MI, which also increased after the additional online portion of the training. Peer leaders reported increased familiarity with MI, belief that it would be effective and should be used with masculine-identifying survivors of unwanted sexual experiences, and willingness to implement the MI intervention. This finding is consistent with another PCORI study of training peers in which Crisanti et al. 29 reported that trauma survivor peers noted increases in their perceived ability to implement a trauma-informed protocol and counsel other survivors and increased comfort in delivering the intervention. As a result of the qualitative feedback provided by the peers, the research team addressed concerns related to learning style (eg, needing smaller but more frequent sessions), the desire to see or experience sessions, and the opportunity to role-play and practice skill development. Indeed, Tsai et al 88 suggested that peer leaders may need MI training and subsequent supervision or booster sessions to improve MI skills. In sum, the following changes and updates were iteratively addressed: created unscripted full-length video demonstrations of group sessions; reduced the length of meetings; reviewed content, practiced role-plays, and developed protocols for hypothetical situations in live meetings; reviewed foundational MI knowledge and skills; and added additional training materials for different learning styles. Reduced attendance during the online sessions was observed after the in-person training, with some peers not attending any of the additional, albeit optional trainings. Although this may be considered an extensive time commitment, it is in line with other peer training programs. 89 Therefore, future trainings might work toward reducing the time commitment through innovative training techniques such as using pre-recorded and self-guided trainings, which may foster greater engagement. Peers demonstrated good MI adherence and competence in both conditions, suggesting that they can be trained and supervised to deliver both the MI and MI+AC well. Peers assigned to MI+AC demonstrated more adherence to AC than those in the MI-only condition, showing peers can be trained to add AC elements to MI in a discriminable way. One potential reason for this may be because supervision in MI+AC focused on self-reflection and lifelong learning about affirming terminology and identities, deferring to participants for their lived experience, and examining one's own biases and beliefs. Surprisingly, for the few instances in which peers who delivered MI only incorporated AC-oriented comments into their sessions, they did so on average more competently than peers in MI+AC. Supervision in the MI condition centered on fundamental patient-centered counseling techniques (eg, reflective listening), which may have spontaneously translated into AC. Aim 2 Discussion Determine the comparative effectiveness of MI and MI+AC on 2 primary outcomes (mental health treatment engagement and depression). Contrary to our hypotheses, there were no differences between MI participants and MI+AC participants in terms of reduction in depressive symptoms or formal engagement in mental health services. This probably speaks to the potent impact of goal-directed, validating peer support on male survivors. However, MI+AC had a significant indirect effect on depression through 3 mediators: interpersonal relationship problems, minority stress expectation of discrimination, and traditional masculine norms about self-reliance. These 3 mediators held up on a multimediator model; thus, they independently mediate depression, but combined together they have a synergistic effect. In particular, MI+AC significantly improved interpersonal functioning scores and lowered scores on minority stress expectations of discrimination and traditional masculine norms about self-reliance, which in turn are associated with decreased depression. One proposed mechanism of action for the MI+AC intervention is the appropriate externalization of minority status-associated stress. Sexual and gender minority men may overly identify with minority stressors and find fault in themselves. The effects that were observed in the mediation analysis seem to suggest that the MI+AC intervention may work by encouraging the reattribution of blame to a cis-normative and heteronormative society, resulting in significantly less internalized helplessness and hopelessness in the form of depression. Furthermore, the role of masculinity and meaning making has been explored and found to be related to psychological outcomes for male survivors. 90-92 By challenging myths related to sexual assault in men, the MI+AC intervention may have provided space for survivors to reconsider the meaning of their unwanted sexual encounters, replacing internalized blame. Aim 3 Discussion Examine SGM trauma survivors' past mental health treatment experiences, perspectives on peer-led MI interventions, and preferences for future mental health treatment. Results of this study provide insight into the past mental health treatment experiences and future preferences of members of the SGM community, who are masculine-identifying, and are survivors of sexual trauma. Contrary to past research that demonstrates cisgender men are often reluctant to seek psychosocial services despite considerable need, 93 , 94 most SGM participants in this sample had sought formal mental health treatment in their lifetime. For many, however, it was only for a short period of time to manage a crisis (eg, hospitalization, job loss) or intermittently during childhood, adolescence, or college, and when it took place it often did not address trauma or related difficulties. Several barriers have been identified for SGM populations in seeking mental health treatment. 95 The systemic adoption of the gender paradigm, which views interpersonal violence as perpetrated by cisgender men against women, often results in intervention services ignoring SGM men's needs and limits access to appropriate services. 96 Indeed, anti-SGM structural stigma, as evidenced in the current study, inhibits members of this community from obtaining trauma-informed, culturally sensitive, and affirming mental health care. Ferlatte et al 97 identified several other systemic and individual-level barriers to seeking mental health services among SGM members with depression and risk of suicide. These included financial barriers (ie, inability to pay and insufficient insurance), preference for dealing with the problems on their own, discomfort discussing emotions, and stigma-related barriers (eg, shame or embarrassment). Similarly, the shortage of affirmative-based professionals and fears of discrimination are also commonly reported. 98 Results of the current study parallel and expand these findings, with SGM male survivors of sexual abuse also expressing that an improper fit with the professional could result in significant setbacks for their recovery. Masculine self-image may also conflict with seeking treatment for mental illness. It has been well documented that traditional masculine ideology can negatively affect help seeking behavior in men. 44 , 99 Participants in the current study noted their reluctance to seek help, believing that they needed to “man up” and deal with their problems on their own. Results of the current study support Pachankis, 100 who provided a review of the extant literature and outlined future directions for SGM-affirmative treatment targets, such as stigma-related stress. Individual-level minority stressors, or a person's cognitive, affective, and behavioral responses to stigma, have been identified as a social determinant of health for SGM populations. 101 Therefore, individual-level minority stress specific to SGMs including internalized homophobia or transphobia (ie, negative attitudes about one's sexual orientation or gender identity), rejection sensitivity (ie, anxious anticipation of rejection because of past experiences with discrimination and prejudice), and concealment (ie, hiding their SGM identity to avoid future victimization) may interfere with or inhibit help-seeking behavior. Indeed, several participants in the current study expressed uncertainty about disclosing their SGM status without knowing how to locate an AC professional. Others expressed reluctance about seeking mental health treatment in the future based on past experiences of discrimination (eg, being sent to therapy because of their SGM status). Symptoms of depression, marginalization, discrimination, and trauma responses may also interfere with seeking help from mental health professionals in this population. In a recent study of more than 1600 men, Levant et al 102 found that men are less likely to seek psychological services for a specific problem to the extent that they adhere to traditional masculine norms, hold negative attitudes about seeking help, and experience self-stigma regarding their need for services. More severely depressed men in that sample, however, were more likely to overcome these barriers and seek counseling than those with lower levels of depression. Results of the current study indicate that SGM men may also need interventions specific to their needs to engage them in mental health care and assist in their symptom reduction. SGM male survivors of sexual abuse expressed interest in and readiness for talking about their trauma. In a qualitative evaluation of a novel intervention that incorporated elements of a trauma processing therapy for reducing trauma symptoms and sexual risk taking among SGM men with childhood sexual abuse, Taylor et al 103 found that the majority of respondents expressed that it was helpful to process and release emotions related to their sexual trauma. Furthermore, these men also reported that not talking about the abuse perpetuated negative emotions. When asked about ways to improve the treatment, SGM men with childhood sexual abuse histories expressed a desire to increase the number of sessions and improve the referral services for additional behavioral health services. Similar to findings from a recent investigation of men who were attending outpatient mental health services in Canada, 104 in our study, individual psychotherapy emerged as the preferred format for treatment, with only a small minority preferring medication. Concerns related to side effects of pharmacotherapy were prominent. Many participants who took medications during their lifetime had negative experiences that precluded them from considering pharmacotherapy in the future. Those who had received benefit from pharmacotherapy, however, expressed a desire to continue treatment as prescribed. The most commonly reported reason for not taking psychiatric medications was the concerns about side effects. Body dissatisfaction and body image concerns are prevalent among SGM men 105 and may result in greater apprehension about use of medications with known physiological side effects of weight gain or sexual dysfunction. Several participants also expressed openness to group therapy, noting that it would be a beneficial adjunct. Lessons Learned Given the prevalence of sexual trauma in the lives of SGM men and its well-documented connection to mental and physical health disorders, reducing their mental health difficulties and facilitating their connection to other survivors and their entry into formal mental health services is important. In addition, given the significant increase in risk for many negative medical and psychiatric diagnoses for trauma survivors, this research has potential to improve understanding of barriers to engagement by trauma survivors in psychosocial interventions. Information garnered may also help underscore additional innovative targets for preventive interventions directed at reducing health disparities in SGM populations. Financial incentives appeared to be very important to many participants, and several participants disengaged or were lost to follow-up after receiving compensation for completing the baseline survey. Nevertheless, we continued to attempt to engage these participants by checking in via email when they missed group sessions, offering to troubleshoot any Zoom or connectivity problems over the phone or during mock Zoom sessions, and sending reminder emails about upcoming sessions. The project is innovative in that it harnesses the strengths of an evidence-based psychotherapy, MI, for behavior change, with the addition of a trauma-informed SGM AC approach. More specifically, scholars 106 have called for mental health care professionals to understand the stigma SGM men face and help them move from internalizing and inappropriate self-blame to appropriate examination of external sociopolitical culture that affects their lives, while fostering coping and support. Affirmative care normalizes and acknowledges the unique stressors that SGM people face, builds emotional awareness, reduces avoidance of feeling negative and painful emotions, promotes the reduction of minority stress cognitions, builds relationships, and affirms healthy sexuality, all within a strength-based approach. 61 Thus, these unique AC considerations add to the relational and technical aspects of MI. Generalizability Results of this study can be generalized to several populations and groups. We found that it was feasible and acceptable to train men who have experienced sexual trauma, suggesting that other sexual trauma survivors may also be effectively trained to deliver these interventions. Also, results of the clinical trial provide some evidence that peer-delivered, online interventions may facilitate formal mental health treatment engagement and reduce depressive symptoms for SGM men who experienced sexual trauma. Furthermore, this study included trans men, an underrepresented population in research. There are some limitations to the generalizability of the study findings. First, participants were recruited primarily through dating websites and apps, and therefore results may not be generalizable to all SGM men. To that end, our population had a shared experience of sexual trauma, which may also limit the generalizability of the findings to people who have been exposed to other types of traumas (eg, combat, motor vehicle crash, natural disaster). Results of the qualitative investigation of mental health needs and preferences may represent only a treatment-seeking population, given that all participants were part of the larger investigation. Subgroup Analyses and Heterogeneity of Treatment Effects As noted above, a significant condition × structural stigma interaction was observed, such that MI+AC had a significantly greater positive impact on reducing depression among participants with lower levels of structural stigma, while among participants with higher levels of structural stigma, MI+AC was associated with higher depression scores. Study Limitations Although the large sample size and statistical sophistication are strengths, results should be understood within limitations. First, this study relied on retrospective reporting of trauma on an online self-report screener for a clinical trial and thus is prone to recollection or reporting bias. Second, previous research indicates that there are high rates of unacknowledged victimization among men. 48 For example, the majority of those who reported behavioral indicators of child sexual abuse did not self-label their own experiences as rape or sexual abuse. It is possible that some of the men who completed this screening did not label their unwanted sexual experiences as sexual victimization, and findings might have been different with trained interviewers administering face-to-face measures with behaviorally oriented questions as opposed to broad questions that allow men to make their own interpretation of what constitutes abuse or assault, resulting in underreporting or selective reporting. Relatedly, this study relied on self-report of sexual orientation identity. Although identity is most often used in research, future investigations might include measurement of other dimensions of sexual orientation, such as attraction and gender of sexual partners. Third, the measurement of sexual victimization was limited. Because there are no widely agreed-upon measures to assess men's experiences with sexual abuse and assault, researchers often adapt tools designed to measure women's sexual victimization experiences. 107 Relatedly, as Shevlin et al 108 pointed out, although research on sexual abuse typologies have received greater attention, most studies are still hampered by use of convenience samples and failure to account for a full range of sexual abuse acts. More extensive, detailed, validated measures of sexual trauma in boys and men are warranted, including relationship to the offender, including whether the perpetrator was extrafamilial or intrafamilial, the age differences between the survivors and the perpetrator, kinds of force or pressure (verbal [bribes, persuasion, threats of withdrawing love] or physical) experienced during an assault, the role of alcohol or drugs, or where the assault occurred. This study also relied on a self-selected sample obtained through various social media and marketing strategies, who elected to seek out the study website for participation. A recent systematic review found that nonprobability samples of SGM people reported higher sexual assault prevalence rates than did population-based or census sample studies. 109 In addition, another review found that nonprobability community samples of SGM people overrepresent those with higher income, current employment, greater numbers of sex partners, suicidal ideation, alcohol use, and substance use. 110 They may also overrepresent people who are comfortable disclosing their sexual orientation and trauma history. Thus, findings should be replicated with a probability or census sampling technique. A notable limitation of the peer leader training program is the potential lack of generalizability, as the sample included people who had expressed interest or were recommended by someone at a nonprofit organization with which they were affiliated. Other studies may use different recruitment methods that could influence how the results of this investigation are applied to future training efforts. This comparative effectiveness trial has several notable strengths, including the large and diverse sample of SGM male survivors and multiple assessments measuring mental health treatment engagement and trauma-related symptoms. In addition, the intervention incorporates the lived experience of peers in leading groups. Moreover, the intervention and accompanying supervision were delivered online, which made both easily accessible and meant minimal disruption of the trial during the COVID-19 pandemic. In addition, there were no untreated control groups in this investigation, and there was a substantial amount of missing data, with evidence that those who participated were quite different from those who did not participate in ways that might affect their response to the interventions. Future Research Participants in both conditions experienced changes over time in depression and treatment engagement. Thus, findings from this trial suggest that engaging in online, peer-delivered MI can lead to declines in depressive symptom and increased mental health treatment engagement for male survivors of sexual abuse who are members of the SGM community. The findings also provide a significant contribution to the extant literature on patient preferences for mental health treatment. More specifically, this work provides a strong foundation of preliminary evidence of the needs and preferences of a traditionally marginalized, underserved, and underrepresented population. Future work should include replication with broader populations and include participants who have experienced other traumas. Conclusions The findings from this PCORI project have several important conclusions. The first is the feasibility and effectiveness of training male sexual abuse or assault survivors without formal mental health training to serve as peers in delivering MI online and in group format to SGM male survivors of sexual abuse and assault. The second is that the 2 peer-led MI interventions appear to be effective at reducing primary outcomes of depression and increasing mental health engagement; however, participants in both conditions made significant changes, and there was no untreated condition. In addition, the use of a trauma-informed AC version of MI was beneficial in interpersonal relationship problems, minority stress expectation of discrimination, and traditional masculine norms about self-reliance. References 1. Dube SR, Anda RF, Whitfield CL, et al. 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Dr Cook, Dr Ellis, and Nathan Lachine, a member of our community partner MaleSurvivor, were interviewed for a PCORI blog in May 2019 about PCORI Engagement Awards that have resulted in research awards. We provided an overview of the partnership between MaleSurvivor and the research team and explained how the project came about and how we designed a comparative effectiveness trial together in response to male survivors' interest. Whitney B. Engagement Awards teams ride momentum to research projects. PCORI blog. May 31, 2019. https://www ​.pcori.org ​/research-in-action ​/engagement-awards-teams-ride-momentum-research-projects •. Dr Cook and Mr Lachine were also invited by PCORI to present at the annual Academy Health meeting in early June 2019. We were one of 4 groups to move beyond an engagement award and receive a larger PCORI grant. We presented as part of a panel (Deepening, expanding, and evolving partnerships in patient-centered outcomes research. Presented at: Academy Health Annual Research Meeting; June 2-4, 2019; Washington, DC. https: ​//academyhealth ​.confex.com/academyhealth ​/2019arm/meetingapp ​.cgi/Session/21755 ). At the meeting, Dr Cook and Mr Lachine were interviewed by PCORI staff on the partnership, and PCORI tweeted out these interviews. •. As part of a collaborative symposium on male survivors of interpersonal violence, Dr Ellis presented on predictors of receipt of mental health services among male survivors of sexual abuse at the annual meeting of the American Psychological Association in Chicago in August 2019. The presentation focused on summarizing additional results from the PCORI Engagement Award regarding predictors of mental health treatment engagement in male survivors (eg, depressive symptoms over and above trauma symptoms). She also presented on how this was the impetus for the current PCORI-funded project, specifically noting the increased risk for shame and stigmatization that reduce the likelihood of masculine-identifying SGM survivors seeking formal mental health services. Thus, this presentation was an opportunity to increase recruitment efforts. – Ellis AE. Predictors of receipt of mental health services in male survivors of sexual abuse. Presented at: Male survivors of interpersonal violence in treatment: research and recommendations symposium, 2019 APA Convention; August 8-11, 2019; Chicago, IL. [ Google Scholar ] •. On August 29, 2019, an op-ed written by Drs Cook and Ellis was published in The Conversation, an independent and not-for-profit member of a global network of newsrooms that publishes in Canada, the United Kingdom, France, Indonesia, Africa, Spain, and Australia. Through a Creative Commons license, The Conversation permits other news organizations and outlets to republish their US articles at no charge. Cook JM, Ellis A. Sexual abuse against gay and bi men brings unique stigma and harm. The Conversation. August 29, 2019. https: ​//theconversation ​.com/sexual-abuse-against-gay-and-bi-men-brings-unique-stigma-and-harm-121796 •. Cook JM, Ellis A. Men tell their stories of rape in the service. The New York Times. October 1, 2019. https://www ​.nytimes.com ​/2019/10/01/opinion ​/letters/trump-impeachment.html •. Cook JM, Ellis A. Tyler Perry and his sexual trauma—what we can learn from this. The Hill. October 4, 2019. https://thehill ​.com/opinion ​/healthcare/464331-tyler-perry-and-his-sexual-trauma-what-we-can-learn-from-this •. LGBTQ+ sexual trauma survivors: motivational interviewing as an approach to clinical work. Trauma Psychology News. December 20, 2019. https: ​//traumapsychnews ​.com/2019/12/lgbtq-sexual-trauma-survivors/ •. Cook J. When are sexually abused in the military. Dr. Vibe podcast. October 10, 2019. https://www ​.thedrvibeshow ​.com/the-dr-vibe-show-dr-joan-cook-when-men-are-sexually-abused-in-the-military/ •. Cook J, Ellis A. Helping sexual and gender minority male survivors heal from sexual trauma. Advocating for Better Mental Health blog. October 17, 2019. https://davidsusman ​.com ​/2019/10/17/helping-sexual-and-gender-minority-male-survivors-heal-from-sexual-trauma/ •. When men are sexually abused in the military. The Good Men Project. October 22, 2019. https: ​//goodmenproject ​.com/featured-content ​/when-men-are-sexually-abused-in-the-military-lbkr/ •. Ellis A. Sexual and gender minorities and sexual abuse. Dr. Vibe podcast. November 4, 2019. https://www ​.thedrvibeshow ​.com/the-dr-vibe-show-live-tonight-at-9-p-m-eastern-6-p-m-pacific-dr-amy-ellis-sexual-and-gender-minorities-and-sexual-abuse/ •. Ellis AE, Cook JM. Five things therapists can do when working with LGBTQ+ individuals. Society for the Advancement of Psychotherapy. November 16, 2019. https: ​//societyforpsychotherapy ​.org/five-things-therapists-can-do-when-working-with-lgbtq-individuals/ •. Dr Cook delivered a presentation for Yale School of Medicine, Department of Psychiatry Grand Rounds, Male Sexual Abuse Survivors: From a PCORI Engagement Award to a Competitive Effectiveness Trial. December 6, 2019. https://medicine ​.yale ​.edu/media-player/yale-psychiatry-grand-rounds-december-6-2019// •. Cook J, Ellis A. Male survivors of sexual assault and abuse. PsychCentral podcast. March 5, 2020. https: ​//psychcentral ​.com/blog/podcast-male-survivors-of-sexual-assault-and-abuse#1 •. Cook JM. Male sexual assault: hidden trauma. Psychiatric Times. December 17, 2019. https://www ​.psychiatrictimes ​.com/view/male-sexual-assault-hidden-trauma •. Cook JM. When boys and men are raped: clinical insights. Psychiatric Times. January 20, 2020. https://www ​.psychiatrictimes ​.com/view/when-boys-and-men-are-raped-clinical-insights •. Ellis AE. The intersection between affectional and gender minority identity, male gender identity, and sexual trauma. Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling Newsletter. 2020. https://nsuworks ​.nova ​.edu/cps_facarticles/1924 •. Cook J, DePrince AP. Dear Donna Rotunno: sexual assault is a public health crisis. Your reckless words hurt all of us. Newsweek. February 20, 2020. https://www ​.newsweek ​.com/dear-donna-rotunno-sexual-assault-public-health-crisis-your-reckless-words-hurt-all-us-1488239 •. Ellis AE. Engaging male-identifying sexual and gender minority sexual trauma survivors in therapy. Association of Lesbian, Gay, Bisexual, and Transgender Issues in Counseling Newsletter. February 21, 2020. https://nsuworks ​.nova ​.edu/cps_facarticles/1921 •. Ellis AE. Providing trauma-informed affirmative care: introduction to special issue on evidence-based relationship variables in working with affectional and gender minorities. Practice Innovations. 2020;5(3):179-188. doi:10.1037/pri0000133 [ CrossRef ] •. Ellis AE, Meade N, Brown LS. Evidence-based relationship variables when working with affectional and gender minority clients: a systematic review. Practice Innovations. 2020;5(3):202-217. doi:10.1037/pri0000118 [ CrossRef ] •. Abbriano K, Ellis AE. Utilizing social support in treating complex trauma in sexual and gender minorities. Society for the Advancement of Psychotherapy. December 2020. https: ​//societyforpsychotherapy ​.org/utilizing-social-support-in-treating-complex-trauma-in-sexual-and-gender-minorities/ •. Cook JM, Ellis AE. The other #MeToo: male survivors. Psychiatric Times. April 8, 2020. https://www ​.psychiatrictimes ​.com/view/other-me-too-male-sexual-abuse-survivors •. Ellis AE, Martino S, Simiola V, Mackintosh MA, Bellamy C, Cook JM. Study design and interventions for a peer-delivered motivational interviewing group treatment for sexual and gender minority male sexual trauma survivors. Contemp Clin Trials. 2021;111:106597. doi:10.1016/j.cct.2021.106597 [ PubMed : 34653650 ] [ CrossRef ] Acknowledgments Funding This work was supported through a PCORI Project Program Award (AD-2018C1-110989). All statements in this report, including its findings and conclusions, are solely those of the authors and do not necessarily represent the views of PCORI or its Board of Governors or Methodology Committee. Additional Acknowledgments The authors thank MenHealing, especially Jim Struve, and MaleSurvivor for partnering on this important endeavor. We also acknowledge and appreciate the peer leaders for their contributions and efforts toward leading the groups, providing input and feedback about the MI protocol, and making the Connect Study an invaluable resource for study participants. We admire the peers greatly and wish for all survivors to know that they are not alone and that healing from sexual trauma is possible, particularly with good support. We also with to thank all the male-identifying survivors who approached us with questions about the study, completed the online surveys and participated in the groups. Research reported in this report was funded through a Patient-Centered Outcomes Research Institute® (PCORI®) Award (AD-2018C1-110989). Further information available at: https://www.pcori.org/research-results/2018/comparing-two-ways-help-sexual-and-gender-minority-men-who-have-been-sexually-abused-reduce-depression-and-increase-mental-health-treatment-engagement#project_study_registation_information Appendices Appendix A. Study Website (PDF, 143K) Appendix B. Patient Preferences and Acceptability (PDF, 314K) Table 1. Themes from qualitative interview of patient preference for mental health treatment and the acceptability of the peer-delivered interventions (PDF, 133K) Original Project Title: Peer Online Motivational Interviewing for Sexual and Gender Minority Male Survivors PCORI ID: AD-2018C1-110989 ClinicalTrials.gov ID: NCT03794986 Suggested citation: Cook JM, Ellis AE, Simiola V, et al. (2023). Comparing Two Ways to Help Sexual and Gender Minority Men Who Have Been Sexually Abused Reduce Depression and Increase Mental Health Treatment Engagement . Patient-Centered Outcomes Research Institute (PCORI). https://doi.org/10.25302/09.2023.AD.2018C1110989 Disclaimer The [views, statements, opinions] presented in this report are solely the responsibility of the author(s) and do not necessarily represent the views of the Patient-Centered Outcomes Research Institute® (PCORI®), its Board of Governors or Methodology Committee. Copyright © 2023. Yale University. All Rights Reserved. This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License which permits noncommercial use and distribution provided the original author(s) and source are credited. (See https://creativecommons.org/licenses/by-nc-nd/4.0/ Bookshelf ID: NBK619818 PMID: 41433686 DOI: 10.25302/09.2023.AD.2018C1110989 Share Views PubReader Print View Cite this Page Cook JM, Ellis AE, Simiola V, et al. Comparing Two Ways to Help Sexual and Gender Minority Men Who Have Been Sexually Abused Reduce Depression and Increase Mental Health Treatment Engagement [Internet]. Washington (DC): Patient-Centered Outcomes Research Institute (PCORI); 2023 Sep. doi: 10.25302/09.2023.AD.2018C1110989 PDF version of this title (2.0M) In this Page Background Patient and Stakeholder Engagement Methods Results Discussion Conclusions References Related Publications Acknowledgments Appendices Other titles in this collection PCORI Final Research Reports Related information NLM Catalog Related NLM Catalog Entries PMC PubMed Central citations PubMed Links to PubMed Recent Activity Clear Turn Off Turn On Comparing Two Ways to Help Sexual and Gender Minority Men Who Have Been Sexually... Comparing Two Ways to Help Sexual and Gender Minority Men Who Have Been Sexually Abused Reduce Depression and Increase Mental Health Treatment Engagement Your browsing activity is empty. Activity recording is turned off. 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