The Lancet Psychiatry: Conversion practice linked to greater risk of mental health symptoms, surveys of LGBTQ+ people in the USA suggest

• Analysis of questionnaires completed by 4,426 LGBTQ+ people in the USA suggests undergoing conversion practice targeting gender identity or sexual orientation is linked with symptoms of depression, PTSD and suicidal thoughts or attempts.
• Cisgender and transgender participants also had more severe symptoms of depression and PTSD if they had undergone conversion practice.
• Cisgender participants subjected to both types of conversion practice had a greater risk of suicidal thoughts and attempts than transgender participants – but mental health symptoms were more severe for transgender people overall, highlighting a need for long-term studies.
• Survey results indicated that religious leaders or organisations tended to lead practices aimed at changing sexual orientation, while mental health care providers or organisations most often led attempts to alter gender identity.
• The authors say the findings underscore the negative impact that conversion practice has on mental health and highlight the need for legislation banning the practices.

People identifying as LGBTQ+ who have undergone conversion practice – commonly known as conversion therapy – are more likely to experience poor mental health, according to a study published in The Lancet Psychiatry journal.

The findings – based on surveys of 4,426 LGBTQ+ adults in the USA – suggest people subjected to controversial practices targeting their gender identity or sexual orientation may be more likely to experience depression, PTSD, and suicidal thoughts or attempts. Transgender participants reported greater mental health symptoms overall.

Conversion practice is a formal, structured attempt to alter a person’s sexual orientation, gender identity, or gender expression. It often involves psychological, behavioural, physical, and faith-based practices. 

When looking at conversion practices aimed only at sexual orientation or practices aimed at both, cisgender and transgender people have a similarly increased likelihood of experiencing symptoms of depression and PTSD. Suicidal thoughts or attempts were higher in cisgender participants subjected to both types of practices than in transgender participants, though it is unclear why, and more research is needed.

Despite widespread opposition from professional medical and mental health organisations, conversion practice still occurs in parts of the USA. How often it is practised in the USA remains unclear – previous research suggests it may be between 4% and 34% of LGBTQ+ people – but significant numbers of LGBTQ+ people report experiencing conversion practice, with rates higher among transgender people compared to cisgender people. [1] It remains legal in many parts of the world, including the UK, parts of Central and Eastern Europe, Asia, and Africa.

Previous research suggests that undergoing conversion practice is linked with mental health conditions, such as depression and suicidal thoughts and attempts. Until now, no studies have examined if the mental health impacts of efforts to alter an individual’s sexual orientation differ from those attempting to change someone’s gender identity. Little was also known about how the effects of these different practices differ between cisgender – people who identify as the sex they were assigned at birth – and transgender people. 

“Our findings add to a body of evidence that shows conversion practice is unethical and linked with poor mental health. Protecting LGBTQ+ people from the impacts of these harmful practices will require multi-pronged legislation, including state and federal bans. Additional measures such as support networks and targeted mental health support for survivors are also vital,” said study author Dr Nguyen Tran, of Stanford University School of Medicine (USA). 

The authors of the new study obtained data for their analysis by surveying participants in The PRIDE Study, a long-term health study of LGBTQ+ people in the USA. [2] Participants completed questionnaires about their experiences of conversion practice, if any, and mental health. Other information recorded included participants’ gender identity, sexual orientation and the sex they were assigned at birth. Participants also reported where they live, their education level, age, ethnic and racial identity, and details of their upbringing (e.g., religious or supportive of LGBTQ+ people).

The authors used statistical analysis to identify associations between conversion practice and mental health conditions. Outcomes were symptoms of anxiety, depression, post-traumatic stress disorder (PTSD), and suicidal thoughts or attempts, which were assessed using established diagnostic scales.

Most participants (92%) identified as White. There were 2,504 (57%) cisgender and 1,923 (43%) transgender participants. Their ages ranged from 18 to 84 years old, with an average of 31 years. 

Of the 4,426 participants, 149 (3.4%) had experienced conversion practice aimed at altering their sexual orientation, 43 (1%) had undergone practices targeting gender identity, and 42 (1%) reported both. 

Participants who had been subjected to conversion practice targeting both their gender identity and sexual orientation had the greatest symptoms of depression, PTSD, and suicidal thoughts or attempts. 

Some participants reported being subjected to conversion practice more than others. These included transgender participants, people experiencing homelessness, and those with lower levels of education. The practices were also more commonly reported among people with religious upbringings, those raised in communities not accepting of their gender identity, and participants from minority ethnic backgrounds. 

Cisgender and transgender participants who had undergone conversion practice had a similarly increased likelihood of depression and PTSD. Neither had increased symptoms of anxiety. However, cisgender participants who had undergone both types of conversion practice had a greater risk of suicidal thoughts or attempts than transgender participants. The authors say there are several possible explanations for differences observed for suicide risk. 

Compared to the wider transgender population, participants in The PRIDE Study may be healthier and have better access to social and financial resources that reduce their likelihood of undergoing conversion practice and experiencing its harmful impacts on mental health. Transgender participants who did not volunteer to participate in The PRIDE Study may include those who are most adversely affected by conversion practices and have poorer mental health outcomes than those who did. There is also potential survivorship bias among transgender participants in The PRIDE Study: fewer transgender people may have lived long enough to participate in the study. Long-term studies that follow young people through to adulthood are needed to gain a clearer picture of the effects of conversion practice among transgender people.

Conversion practice aimed at altering an individual’s sexual orientation was most often delivered by a religious leader or organisation (52%, 100/191 participants), followed by a mental health provider or organisation (29%, 55/191). Practices targeting participants’ gender identity were most commonly delivered by mental health care providers or organisations (54%, 46/85 participants), followed by a religious leader or organisation (33%, 28/85) and both (13%, 11/85). 

“Our findings suggest that effective policy interventions may need multi-pronged legislative actions at the federal, state, and local levels, including state and federal bans on conversion practice. Educational efforts involving families, religious leaders, and mental health providers are also needed, as are support networks for LGBTQ+ youths and targeted mental health screening to identify and support survivors of conversion practice,” said Tran. 

The authors acknowledge some limitations to their study. Errors in people’s recollections may have led to the misclassification of some experiences of conversion practice. Some potentially important childhood factors – such as family rejection of participants’ gender identity – were not considered in the analysis, and should be examined in future studies. The study cohort may not include people whose mental health has been most impacted by conversion practice, as it could lead to delays in their willingness to publicly share their identity or be involved in studies such as The PRIDE Study. 

Writing in a linked Comment, Jack Drescher, MD, Clinical Professor of Psychiatry at Columbia University Medical Center (USA), who was not involved in the study, said: “An important message from the Article by Tran and colleagues is that mainstream mental health organisations need to do a better job of regulating the activities of those outlier, licensed clinicians who engage in conversion practices … professional organisations’ ethical guidelines should mirror and integrate the wider world’s changing cultural beliefs and values regarding the growing acceptance of diverse sexual orientations and gender identities.” He adds, “rather than unwarranted and unhelpful clinical preoccupations with asking why a patient has the sexual orientation or gender identity that they are reporting, it is more clinically useful to ask how to help such individuals more openly and adaptively live their lives, while always keeping in mind the medical dictum to first do no harm.”

NOTES TO EDITORS

This study was funded by the Gill Foundation, Patient-Centered Outcomes Research Institute and a philanthropic gift from Dona Rockstad. It was conducted by researchers from Stanford University, University of Washington, Oregon Health & Science University-Portland State University, Boston University, Public Democracy America and University of California San Francisco.]

Quotes from Authors cannot be found in the text of the Article, but have been supplied for the press release. The Comment quote is taken directly from the linked Comment.

[1] https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0291768 
[2] https://pridestudy.org/

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