Clinical High Risk for Psychosis in Sexual and Gender Minority Populations: Considerations for Assessment and Treatment

Abstract

Psychosis exists on a spectrum, ranging from unusual experiences to impairing disorders. Individuals at clinical high risk for psychosis (CHR-p) experience subthreshold yet clinically significant (ie, distressing, impairing) symptoms. As such, CHR-p symptomatology indicates increased vulnerability for full-threshold psychosis and marks a critical intervention period. This experience of heightened risk is especially relevant for youth from minoritized groups, such as sexual and gender minority (SGM) populations, who experience increased stress due to discrimination and stigma. CHR-p research in SGM populations is limited, with work needed to more accurately assess risk for psychosis and identify unique interventions in this group. This article serves as a call to action and addresses gaps in our understanding of psychosis risk in SGM populations in several ways. We review diathesis-stress models of psychosis and incorporate tenets of minority stress theory to highlight how social and environmental stressors may contribute to invalidating environments and the emergence of psychosis spectrum experiences. We then review evidence from psychosis studies and ongoing CHR-p research that suggests SGM populations are at increased risk for developing psychosis, including contextual factors that may pose mediating mechanisms of risk. Potential barriers to recruitment of SGM youth in CHR-p research and barriers to care are also described. Clinical and research suggestions are made to encourage the enrollment and retention of SGM youth in CHR-p studies and clinical settings. We conclude by discussing the importance of implementing identity-affirming practices across research settings and intervention models to center experiences of SGM youth when both conceptualizing and treating CHR-p symptoms.