Gender Identify Conversion Efforts Up Lifetime Suicidality Risk

A new study has found that any exposure to an attempt to convert someone to a gender they do not identify with is associated with adverse mental health outcomes, including an increased lifetime risk of suicide attempts and suicidal ideation.

The cross-sectional observational study is the first to assess whether lifetime exposure to gender identity conversion efforts (GICE) has an impact on mental health, and also the first to specifically assess whether such attempts before the age of 10 have an impact on mental health in adulthood.

"This is the first study to show that attempts to change a person's gender identity from transgender to cisgender are associated with suicide attempts," lead author Jack Turban, MD, MHS, told Medscape Medical News.

"This was true both for attempts during childhood and later in life. It was also true regardless of whether the attempts were by a secular therapist or a religious advisor," said Turban, resident physician in psychiatry at Massachusetts General Hospital in Boston and McLean Hospital in nearby Belmont.

"After adjusting for statistically significant demographic variables, lifetime exposure to GICE was significantly associated with multiple adverse outcomes, including severe psychological distress during the previous month (adjusted odds ratio [aOR], 1.56; 95% confidence interval [CI], 1.09 - 2.24, P < .001) and lifetime suicide attempts (aOR, 2.27; 95% CI, 1.60 - 3.24; P <.001)," write Turban and colleagues in a study published online yesterday in JAMA Psychiatry.

When asked to comment, William Byne, MD, PhD, professor of clinical psychiatry at Columbia University Vagelos College of Physicians and Surgeons in New York City, said, "It's an important study, but I don't think the results are surprising."

"We've known that there's a strong association between gender minority stress and poor health outcomes," Byne told Medscape Medical News. "This just makes it a little bit more concrete."

As both Turban and Byne pointed out, the American Medical Association, the American Psychiatric Association, the American Academy of Child and Adolescent Psychiatry, the American Academy of Pediatrics, and the American College of Physicians, among other organizations, have issued policy statements calling GICE both unethical and ineffective.

According to the Human Rights Campaign, 17 states and Washington, DC have laws that, through licensing restrictions, prevent licensed mental health service professionals from conducting conversion therapy on anyone under age 18. But these laws do not pertain to religious advisors or other non-healthcare professionals, some of whom engage in conversion therapy.

Also, as HRC notes, as many as 20,000 LGBTQ youth in 2018 alone could be vulnerable to conversion therapy in states without such laws.

An estimated 1.4 million American adults identify as transgender, according to a study by the Williams Institute, University of California, Los Angeles.

Increased Suicidality

The current study, based on the National Center for Transgender Equality's 2015 US Transgender Survey, analyzed responses from 27,715 transgender adults living in the US, who were from all 50 states, Washington, DC, American Samoa, Guam, Puerto Rico, and US military bases overseas. The mean age of the respondents was 31.

It found that, overall, about 71% (19,741) had spoken to a professional about their gender identity. Among those, 3869 (19.6%) said they had been exposed to a conversion attempt.

About 43% (11,857) of the nearly 28,000 survey respondents were assigned male at birth.

But the majority of those who said a professional had tried to make them identify only with their sex assigned at birth were born female (2726, or 70.5% of the 3869 respondents exposed to GICE).

The analysis compared mental health outcomes among transgender adults exposed to GICE to those who had discussed gender identity but had not been subjected to GICE.

The authors found that GICE was significantly associated with suicidal ideation and ideation with a plan in the previous 12 months, and also with lifetime ideation and attempts. It was also statistically significantly associated with severe psychological distress (defined as a score of greater than 13 on the Kessler Psychological Distress Scale).

The study also found that 206 (1%) respondents reported exposure to GICE before age 10. In those individuals, GICE was significantly associated with lifetime suicide attempts, with an adjusted odds ratio of 4.15.

This was higher than for those who had exposure at other points in their life, "suggesting that rejection of gender identity may have more profound consequences at earlier stages of development," the authors write.

Byne agreed that the earlier the attempt, the more potential for damage. "When children are told that their gender identity, or what they feel comes naturally to them, is not acceptable, I think it takes a huge toll on self-esteem and resilience going forward," he told Medscape Medical News.

Survey respondents from socioeconomically disadvantaged groups also reported GICE exposure more often.

Conversion Correlated With Healthcare?

The authors said the study suggests that transgender people are exposed to GICE at higher rates than cisgender nonheterosexual individuals — where the goal is to convert sexual orientation.

This could be because "many persons in the gender minority group must interact with clinical professionals to be medically and surgically affirmed in their identities," write Turban and his colleagues. The higher prevalence of interactions with clinical professionals "may lead to greater risk of experiencing conversion efforts," they note.

About 35% of those who reported exposure to GICE during their lifetime said that the attempts came from a religious adviser — which means that 65% were exposed to GICE by a health professional.

That may not be totally surprising. "Current training of mental health clinicians in the US does not usually include gender-affirming care as standard curriculum," said senior author Alex Keuroghlian, MD, MPH, psychiatrist at Massachusetts General and director of the National LGBT Health Education Center at The Fenway Institute.

"All clinicians need to be trained in concepts and terminology related to gender identity, how stigma is related to mental health disparities, and best practices for gender affirmation grounded in scientific evidence," Keuroghlian told Medscape Medical News.

The study found it made no difference whether GICE was attempted by a healthcare professional or a religious or other adviser. "Any process of intervening to alter gender identity is associated with poorer mental health regardless of whether the intervention occurred within a secular or religious framework," they write.

"Rejection is rejection regardless of where it comes from," said Byne. "Whether the attempt to change this fundamental aspect of the individual comes from a religious entity or from a mental health professional is probably not as important as what the message is itself — that the person is unacceptable in some way as they are and needs to change," he said.

Survey Model Means Limitations

The authors said that using a survey as the basis of analysis had both strengths and limitations. It was a large sample size, covering respondents from all areas of the US.

But, as Byne points out, it is not a probability sample, "so we don't know how selection bias may have impacted those who responded to the survey."

It's also possible that individuals with worse mental health or internalized transphobia may have been more likely to seek out conversion therapy, and thus the conversion efforts may not have led to the adverse outcomes, said the authors. But they also added that poor mental health initially could be a response to societal rejection.

The survey responses did not allow for any descriptions of GICE — what was attempted, duration, frequency, etc. And the survey did not ask about exposure to GICE from others, such as family members.

But the study suggests that the bottom line is "that GICE should be avoided with children and adults," the authors conclude.

"Transgender people and their families ought to feel empowered to pursue only gender-affirming professional care, knowing that conversion efforts are not ethical, safe, or effective," said Keuroghlian.

They can also "ask professionals questions about their approach to care, in order to avoid engaging with professionals who do not clearly offer gender-affirming services," Keuroghlian said, adding that clinicians and others "who believe conversion efforts work ought to read this research study, in order to understand the significantly increased risk of attempting suicide that is linked to conversion efforts."

This work was supported by a grant from the Health Resources and Services Administration Bureau of Primary Health Care, partly supported by a grant from the National Institutes of Health, and an American Academy of Child and Adolescent Psychiatry Pilot Research Award for General Psychiatry Residents. Turban reported collecting royalties from Springer for an upcoming textbook about pediatric gender identity. Keuroghlian and the other study authors have disclosed no relevant financial relationships. Byne has disclosed no relevant financial relationships.

JAMA Psychiatry. Published online September 11, 2019. Abstract

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