Conversion Practices Tied to Greater Symptoms of PTSD, Suicidality

Exposure to conversion practices was associated with increases in several mental health symptoms for sexual and gender minority individuals, according to a cross-sectional study.

The analysis of more than 4,000 people revealed that self-reported exposure to both gender identity and sexual orientation conversion practices was linked with greater symptoms of post-traumatic stress disorder (PTSD) (β 2.84, 95% CI 0.94-4.74) and suicidality (β 2.14, 95% CI 0.95-3.32) compared to those without any exposure, according to Mitchell R. Lunn, MD, of Stanford University School of Medicine in California, and colleagues.

Notably, self-reported exposure to conversion practices for gender identity alone was most strongly associated with greater depressive symptoms (β 3.24, 95% CI 1.03-5.46) compared to those without exposure, they reported in the Lancet Psychiatry.

“LGBTQIA+ individuals faced adverse mental health outcomes associated with exposure to conversion practices,” co-author Nguyen K. Tran, PhD, MPH, also of Stanford, told MedPage Today. “The findings underscore the need for protective policies, affirming mental health care, and supportive resources for LGBTQIA+ individuals exposed to these practices.”

Participants reported that most sexual orientation conversion practices were initiated by religious leaders or organizations (52.4%). But they also found that mental health providers or organizations played a role in conversion practices, reporting that 28.8% of facilitators for sexual orientation conversion practices, and 54.1% of facilitators for gender identity conversion practices, were mental health providers.

Tran said the findings highlight “that these harmful practices continue to occur, not only within religious groups but also among mental health professionals, despite explicit opposition from multiple healthcare governing bodies such as the American Psychiatric Association [APA].”

He added that the findings emphasize the need for mental health care that is affirming and supportive for LGBTQIA+ individuals.

“There are several key strategies for LGBTQIA+ individuals that have experienced conversion practice, including connecting individuals with supportive LGBTQIA+ networks; providing affirming mental healthcare that respects diverse gender identities and sexual orientations; and fostering self-esteem as individuals embrace their authentic selves,” Tran said.

In an accompanying comment, Jack Drescher, MD, of Columbia University Medical Center in New York City, said the study offered important findings considering psychiatry’s history with therapeutic efforts toward a sexual orientation, including the APA’s “1974 decision to replace the DSM-II diagnosis of homosexuality per se with sexual orientation disturbance, which was revised in 1980 in DSM-III as ego dystonic homosexuality.”

He noted that those diagnoses were used to justify conversion practices in the past, but the field has come to understand the harms caused by those practices.

“Mainstream mental health organizations need to do a better job of regulating the activities of those outlier, licensed clinicians who engage in conversion practices,” Drescher wrote. “For just as the current iterations of DSM and ICD have evolved over time, 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.”

Lunn’s group collected data on 4,426 participants from The Pride Study, a U.S.-based, online, prospective cohort study of sexual and gender minority adults, who completed a lifetime questionnaire in 2019-2020 and again in 2020-2021, which asked two “yes/no” questions: “Have you ever been in therapy or been part of a program or group intended to change your gender or gender identity to be consistent with the sex assigned to you at birth?” and “Have you ever been in therapy or been part of a program or group intended to change your sexual orientation to heterosexual/straight?”

Overall, 92% of participants identified as white, 43.4% identified as transgender and gender diverse, and they had a median age of 31.7. Of sexual and gender minority participants, 5.4% reported exposure to any conversion practice, including 3.4% for sexual orientation-related conversion practice alone, 1% for gender identity-related conversion practice alone, and 1% for both. More than three-fourths reported that they were not raised in a community that was accepting of sexual and gender minority.

The authors noted that mental health outcomes were continuous measures, using Generalized Anxiety Disorder 7-item scale (GAD-7; scores of 0-21 indicating minimal to severe anxiety), Patient Health Questionnaire 9-item scale (PHQ-9; 0-27 with higher score indicating more severe depression), Post-Traumatic Stress Disorder Checklist 6-item scale (PCL-6; score of 50 likely indicating PTSD), and Suicide Behaviors Questionnaire-Revised scale (SBQ-R; scores ranging from 3-18 for lifetime suicide ideation and/or attempt). They reported that for the entire study population, the mean GAD-7 score was 7.4, the mean PHQ-9 score was 8.0, the PCL-6 score was 14.0, and the SBQ-R score was 8.7.

They used linear regression to analyze the associations of conversion practice recall and mental health symptoms. They also controlled for demographic and childhood factors and stratified between cisgender and transgender and gender diverse groups.

Study limitations included the fact that the data came from an online, community-engaged, non-probability sample, which may not be representative of the most adversely affected individuals. And while the authors conducted sensitivity analyses to account for potential bias, they could not make any causal interpretations due to the cross-sectional design of the study. Finally, the self-reported measures were susceptible to recall bias.

If you or someone you know is considering suicide, call or text 988 or go to the 988 Suicide and Crisis Lifeline website.

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