Experiences with sexual orientation and gender identity conversion therapy practices among sexual minority men in Canada, 2019-2020

Conversion practice recall and mental health symptoms in sexual and gender minority adults in the USA: a cross-sectional study

BACKGROUND

Conversion practices are associated with psychological morbidity, yet few studies have evaluated differences between efforts to change gender identity, sexual orientation, or both. We aimed to examine the individual and joint association of conversion practice recall targeted at gender identity or sexual orientation, or both, with current mental health symptoms among sexual and gender minority people.

METHODS

This cross-sectional study used data from The PRIDE Study, a US-based, online, prospective cohort study of sexual and gender minority adults who were recruited through social media, digital advertisements, and sexual and gender minority community-based events and organisations. For this analysis, we included participants who completed a lifetime questionnaire in 2019-20 and a subsequent annual questionnaire in 2020-21 without missing outcome data. All questionnaires were in English. The exposure was lifetime recall of conversion practice targeting gender identity alone, sexual orientation alone, or both (versus no conversion practice). Mental health outcomes were continuous measures: Generalized Anxiety Disorder 7-item scale, Patient Health Questionnaire 9-item (depression) scale, Post-Traumatic Stress Disorder Checklist 6-item scale, and Suicide Behaviors Questionnaire-Revised scale. We used linear regression to analyse the associations of conversion practice recall and mental health symptoms, controlling for demographic and childhood factors and stratified between cisgender and transgender and gender diverse groups. Sensitivity analyses evaluated the potential impact of unmeasured confounding. Analyses were conducted in R. We included people with related lived experience in the design and implementation of this study.

FINDINGS

Of 6601 participants who completed the lifetime questionnaire in 2019-20, 4440 completed the subsequent annual questionnaire in 2020 or 2021, and 4426 did not have missing outcome data. Of the 4426 included participants, 4073 (92·0%) identified as White (either alone or in combination with other ethnoracial options), 460 (10·4%) identified with multiple ethnoracial identities, and 1923 (43·4%) were transgender and gender diverse. Participants' age ranged from 18 years to 84 years (median 31·7 years, IQR 25·5-44·1). 149 (3·4%) participants reported sexual orientation-related conversion practice alone, 43 (1·0%) reported gender identity-related conversion practice alone, and 42 (1·0%) reported both. Recalling both forms of conversion practice was most strongly associated with greater post-traumatic stress disorder (PTSD; β 2·84, 95% CI 0·94-4·74) and suicidality (2·14, 0·95-3·32) symptoms. Recall of only sexual orientation-related conversion practice was associated with greater symptoms of PTSD (1·10, 0·22-1·98). Recall of gender identity-related conversion practice alone was most strongly associated with greater depressive symptoms (3·24, 1·03-5·46). Only associations for suicidality differed between cisgender and transgender and gender diverse participants, although the latter showed higher mental health symptoms overall. Findings were moderately robust to potential sources of unmeasured confounding in sensitivity analysis.

INTERPRETATION

Recall of conversion practice exposure was associated with a range of mental health symptoms among sexual and gender minority people. These findings support calls to ban conversion practices because of their effects as a structural determinant of mental health.

FUNDING

Gill Foundation, Dona Rockstad, and Patient-Centered Outcomes Research Institute.

Geographic distribution of conversion therapy prevalence in Canada. Findings from a national cross-sectional survey, 2020

BACKGROUND

Conversion therapy practices (CTPs) are discredited efforts that target lesbian, gay, bisexual, trans, queer, Two-Spirit, or other (LGBTQ2S+) people and seek to change, deny, or discourage their sexual orientation, gender identity, and/or gender expression. This study aims to investigate the prevalence of CTPs across Canadian provinces and territories and identify whether CTP bans reduce the prevalence of CTPs.

METHODS

We collected 119 CTPs from 31 adults (18+) in Canada who have direct experience with CTPs, know people who have gone to CTPs, or know of conversion therapy practitioners using a 2020 anonymous online survey. Mapping analysis was conducted using ArcGIS Online. CTP prevalence was compared between provinces/territories with and without bans using chi-square tests.

RESULTS

Three provinces and eleven municipalities had CTP bans. The prevalence of CTPs in provinces/territories with bans was 2.34 per 1,000,000 population (95% CI 1.65, 3.31). The prevalence of CTPs in provinces/territories without bans was 4.13 per 1,000,000 population (95% CI 3.32, 5.14). Accounting for the underlying population, provinces/territories with the highest prevalence of CTPs per 1,000,000 population were New Brunswick (6.69), Nova Scotia (6.50), and Saskatchewan (6.37).

CONCLUSIONS

Findings suggest only 55% of Canadians were protected under CTP bans. The prevalence of CTPs in provinces/territories without bans was 1.76 times greater than provinces/territories with bans. CTPs are occurring in most provinces/territories, with higher prevalence in the west and the Atlantic. These findings and continued efforts to monitor CTP prevalence can help inform policymakers and legislators as society is increasingly acknowledging CTPs as a threat to the health and well-being of LGBTQ2S+ people.

"When Can I Call Home?" Coercive Control, Structural Isolation, and Functional Isolation Among Attendees of Residential Behavioral Modification Programs

The "Troubled Teen Industry" refers to a network of federally unregulated programs marketed toward the behavior modification of teens through therapeutic intervention and elite education. The true nature and structure of these programs, however, remains relatively unstudied, with the consequences of program attendance largely unknown or based on anecdotal evidence. This study systematically analyzes 77 open-source testimonials of former program attendees for themes of coercive control and isolation. Thematic analyses revealed high rates of coercive control within these narratives. In total, 66 narratives mentioned themes associated with coercive control that were unrelated to isolation. Specifically, respondents experienced frequent psychological abuse, gaslighting, humiliation, and name calling. Additionally, a total of 69 narratives contained themes of coercive control specific to functional or structural isolation. The lack of privacy combined with fear of staff retaliation for disobedience lead to structural and functional isolation among program attendees, preventing program attendees from engaging in help-seeking behaviors. Study results provide critical information as to the functioning of these programs, the experiences of youth involved with these programs, and how youth involved may be affected. Such findings justify the dedication of resources to further research this population and encourages the development of federal policy regarding the functioning of these institutions.

Conversion practices in Aotearoa New Zealand: Developing a holistic response to spiritual abuse

Research arising from conversion practices, also known as conversion therapy and sexual orientation and gender identity change efforts, has generally been underpinned by an emancipatory discourse that has evolved to counter harmful practices by evidencing associated harms and estimating prevalence. Little attention, however, has focused on what is required to support survivors, inclusive of those currently or those having previously experienced conversion efforts. Within a context of Aotearoa New Zealand having recently criminalised conversion practices, this study adopted an in-depth qualitative research design, informed by a dual adherence to life history and an empowerment methodology. Twenty-three religious conversion practice survivors, who had experienced religious conversion practices across a range of Christian identified faith settings, were interviewed. Participants had a median age of 34 and the majority identified as New Zealand European, cisgender, and gay. Participant narratives were discursively analysed. Three primary discourses were identified that inform the needed development of interventions and supports: 1) pervasive framing of conversion practices as harm, rather than spiritual abuse, has minimised the impacts of conversion practices. Rather, conceptualising conversion as spiritual abuse positions conversion practices as requiring urgent intervention and ongoing support, inclusive of the development of policy and operational responses; 2) the coercive nature of spiritual abuse needs to be appreciated in terms of spiritual, social, and structural entrapment; 3) the metaphor of a pipeline was enlisted to encapsulate the need for a multidimensional array of interventions to ensure those entrapped within spiritual abuse have a "pipeline to safety". Holistic survivor-centric conversion-related responses to spiritual abuse are required. These need to be informed by an understanding of entrapment and the associated need for holistic responses, inclusive of extraction pathways and support for those entrenched within abusive religious settings, support immediately after leaving abusive environments, and support throughout the survivors' healing journeys.

Inequities in Conversion Practice Exposure at the Intersection of Ethnoracial and Gender Identities

Objectives. To examine inequities in conversion practice exposure across intersections of ethnoracial groups and gender identity in the United States. Methods. Data were obtained from The Population Research in Identity and Disparities for Equality Study of sexual and gender minority people from 2019 to 2021 (n = 9274). We considered 3 outcomes: lifetime exposure, age of first exposure, and period between first and last exposure among those exposed to conversion practices. We used log-binomial, Cox proportional hazards, and negative binomial models to examine inequities by ethnoracial groups and gender identity adjusting for confounders. We considered additive interaction. Results. Conversion practice prevalence was highest among minoritized ethnoracial transgender and nonbinary participants (TNB; 8.6%). Compared with White cisgender participants, minoritized ethnoracial TNB participants had twice the prevalence (prevalence ratio = 2.16; 95% confidence interval [CI] = 1.62, 2.86) and risk (hazard ratio = 2.04; 95% CI = 1.51, 2.69) of conversion practice exposure. Furthermore, there was evidence of a positive additive interaction for age of first exposure. Conclusions. Minoritized ethnoracial TNB participants were most likely to recall experiencing conversion practices. Public Health Implications. Policies banning conversion practices may reduce the disproportionate burden experienced by minoritized ethnoracial TNB participants. (Am J Public Health. 2024;114(4):424-434. https://doi.org/10.2105/AJPH.2024.307580).

Estimation of the population size of gay, bisexual and other men who have sex with men in Canada, 2020

Background

Gay or bisexual (GB) and other men who have sex with men (MSM) are disproportionately affected by human immunodeficiency virus (HIV) globally and domestically in Canada. Reliable and recent population size estimates are necessary to allocate resources to meet prevention needs and for modelling the HIV epidemic. However, previous direct estimates did not account for GB men who would not reveal their sexual identity to a government survey, nor MSM not identifying as GB. The objective of this study was to develop two national population size estimates of gay, bisexual and other men who have sex with men (gbMSM) in 2020. First, GB men based on identity, regardless of sexual experience, and MSM who do not identify as GB but reported anal sex with a man in the past 1-5 years ("Identity-or-Behaviour" estimate). Second, an estimate of gbMSM who reported past 6-12 months anal sex with a man ("Behaviour-only" estimate).

Methods

Estimates for males aged 15 years and older were drawn from Statistics Canada's population size estimates, the Canadian Community Health Survey and the Community-Based Research Centre's Sex Now Survey. Estimated proportions of GB identity, those not likely to disclose GB identity and MSM who do not identify as GB but who reported past 1-5 years anal sex were applied. Past 6-12 months anal sex history was subsequently used to limit estimates to those sexually active anally.

Results

It was estimated that 3.5% of the male population in Canada aged 15 years and older identified as GB. Of GB males, 86.5% were likely to disclose their sexual identity to a government survey. A further 0.1% of non-GB identified males reported past year anal sex with a man. The national Identity-or-Behaviour gbMSM population size in 2020 was estimated at 669,613 people, equivalent to 4.3% of the Canadian male population aged 15 years and older. The estimate of Behaviour-only gbMSM was 412,186, representing 2.6% of the Canadian male population aged 15 years and older.

Conclusion

Using data from multiple sources, a model applied to estimate the population size of gbMSM, accounting for populations previously not included in prior estimates, has been described.

A systematic review of the prevalence of lifetime experience with 'conversion' practices among sexual and gender minority populations

RATIONALE

Conversion practices (CPs) refer to organized attempts to deter people from adopting or expressing non-heterosexual identities or gender identities that differ from their gender/sex assigned at birth. Numerous jurisdictions have contemplated or enacted legislative CP bans in recent years. Syntheses of CP prevalence are needed to inform further public health policy and action.

OBJECTIVES

To conduct a systematic review describing CP prevalence estimates internationally and exploring heterogeneity across country and socially relevant subgroups.

METHODS

We performed literature searches in eight databases (Medline, Embase, PsycInfo, Social Work Abstracts, CINAHL, Web of Science, LGBTQ+ Source, and Proquest Dissertations) and included studies from all jurisdictions, globally, conducted after 2000 with a sampling frame of sexual and gender minority (SGM) people, as well as studies of practitioners seeing SGM patients. We used the Hoy et al. risk of bias tool for prevalence studies and summarized distribution of estimates using median and range.

RESULTS

We identified fourteen articles that reported prevalence estimates among SGM populations, and two articles that reported prevalence estimates from studies of mental health practitioners. Prevalence estimates among SGM samples ranged 2%-34% (median: 8.5). Prevalence estimates were greater in studies conducted in the US (median: 13%), compared to Canada (median: 7%), and greater among transgender (median: 12%), compared to cisgender (median: 4%) subsamples. Prevalence estimates were greatest among people assigned male at birth, whether transgender (median: 10%) or cisgender (median: 8%), as compared to people assigned female at birth (medians: 5% among transgender participants, 3% among cisgender participants). Further differences were observed by race (medians: 8% among Indigenous and other racial minorities, 5% among white groups) but not by sexual orientation.

CONCLUSIONS

CPs remain prevalent, despite denouncements from professional bodies. Social inequities in CP prevalence signal the need for targeted efforts to protect transgender, Indigenous and racial minority, and assigned-male-at-birth subgroups.

Sampling Sexual and Gender Minority Youth With UnACoRN (Understanding Affirming Communities, Relationships, and Networks): Lessons From a Web-Based Survey

BACKGROUND

Periodic surveys of sexual and gender minority (SGM) populations are essential for monitoring and investigating health inequities. Recent legislative efforts to ban so-called conversion therapy make it necessary to adapt youth surveys to reach a wider range of SGM populations, including those <18 years of age and those who may not adopt an explicit two-spirit, lesbian, gay, bisexual, transgender, and queer (2S/LGBTQ) identity.

OBJECTIVE

We aimed to share our experiences in recruiting SGM youth through multiple in-person and online channels and to share lessons learned for future researchers.

METHODS

The Understanding Affirming Communities, Relationships, and Networks (UnACoRN) web-based survey collected anonymous data in English and French from 9679 mostly SGM respondents in the United States and Canada. Respondents were recruited from March 2022 to August 2022 using word-of-mouth referrals, leaflet distribution, bus advertisements, and paid and unpaid campaigns on social media and a pornography website. We analyzed the metadata provided by these and other online resources we used for recruitment (eg, Bitly and Qualtrics) and describe the campaign's effectiveness by recruitment venue based on calculating the cost per completed survey and other secondary metrics.

RESULTS

Most participants were recruited through Meta (13,741/16,533, 83.1%), mainly through Instagram; 88.96% (visitors: 14,888/18,179) of our sample reached the survey through paid advertisements. Overall, the cost per survey was lower for Meta than Pornhub or the bus advertisements. Similarly, the proportion of visitors who started the survey was higher for Meta (8492/18,179, 46.7%) than Pornhub (58/18,179, 1.02%). Our subsample of 7037 residents of Canada had a similar geographic distribution to the general population, with an average absolute difference in proportion by province or territory of 1.4% compared to the Canadian census. Our US subsample included 2521 participants from all US states and the District of Columbia. A total of CAD $8571.58 (the currency exchange rate was US $1=CAD $1.25) was spent across 4 paid recruitment channels (Facebook, Instagram, PornHub, and bus advertisements). The most cost-effective tool of recruitment was Instagram, with an average cost per completed survey of CAD $1.48.

CONCLUSIONS

UnACoRN recruited nearly 10,000 SGM youth in the United States and Canada, and the cost per survey was CAD $1.48. Researchers using online recruitment strategies should be aware of the differences in campaign management each website or social media platform offers and be prepared to engage with their framing (content selection and delivery) to correct any imbalances derived from it. Those who focus on SGM populations should consider how 2S/LGBTQ-oriented campaigns might deter participation from cisgender or heterosexual people or SGM people not identifying as 2S/LGBTQ, if relevant to their research design. Finally, those with limited resources may select fewer venues with lower cost per completed survey or that appeal more to their specific audience, if needed.

Sexual Orientation and Gender Identity Change Efforts for Young People in New Zealand: Demographics, Types of Suggesters, and Associations with Mental Health

Sexual orientation and gender identity change efforts (SOGICE) are harmful practices, yet who suggests them to young people and what impacts are associated with these suggestions have received limited attention in the literature. The present study explored whether certain suggesters, and the frequency of categories of suggesters (including religious leaders, family members, and health professionals), were associated with suicidality and non-suicidal self-injury (NSSI). The study also explored whether particular demographics of young people were more likely to report SOGICE experiences. Data were collected through an online survey of New Zealand gender- and sexuality-diverse youth. The sample (n = 3948) had an age range of 14-26 (mean age = 18.96), and approximately half (52.4%) were transgender or gender-diverse. Odds of suicidality and NSSI were highest when religious leaders suggested SOGICE and when more than one type of suggester was reported. SOGICE was more likely to be reported by transgender and gender-diverse youth, statutory care- and homelessness-experienced youth, and young people reporting current material deprivation. Implications for targeted mental health services and education for young people and the community are discussed.

A Qualitative Approach to Exploring the Impact of the Gay Identity Formation Process

Background

Most gay men experience difficulty in coming to terms with their sexual orientation, with their health, wellbeing, and quality of life potentially affected by unpleasant experiences often associated with the formation of their gay identity. It is therefore important for nurses to understand the needs of gay men so that they can accompany them and provide quality care during and after the identity formation process.

Objective

The aim of the study was to explore and describe the identity formation and coming out experiences of gay men.

Methods

A qualitative design with a constructivist naturalist approach was used. Data were collected through in-depth semi-structured interviews with five gay men with experience of the gay identity formation process, and data were analyzed using a thematic analysis method.

Results

The results show that the men needed support, as they reported feeling different and alone during the identity formation and coming out process, and that their mental health was affected. Fear of rejection, negative reactions, and disappointing people were the reasons that led the men not to disclose their sexual orientation to family, while those who had come out defined a feeling of liberation.

Conclusions

The gay identity formation process has potential impacts on health, wellbeing, and quality of life. Nurses need cultural competence training to be able to understand the needs of gay men, accompany them in the identity formation process, and provide individualized and non-heteronormative care. Nurses also need to participate in dismantling a heterosexist social structure.

Cisheteronormativity, Conversion Therapy, and Identity Among Sexual and Gender Minority People: A Narrative Inquiry and Creative Non-fiction

Sexual and gender minorities (SGMs) navigate systems of oppression that reify cisgender and heterosexual norms (cisheteronormativity) while developing their identities. 'Conversion therapy' represents a particularly prominent and harmful threat in this landscape. We explore how SGM who experienced conversion therapy develop their identities to understand antecedents to mental health struggles in this population. In-depth interviews were conducted with 22 people in Canada. A 'master narratives' framework combined with Polkinghorne's narrative analysis were used to explore individual-structural relations that affect identity in settings where cisheteronormative master narratives are amplified (i.e., conversion therapy). We present research findings through a creative non-fiction, which includes learning cisheteronormative master narratives; internalizing master narratives; feeling broken and searching for alternatives; and embracing self-love amidst pain. The amplification of master narratives through conversion therapy leads to conflict and delays in adopting a coherent identity. Health professionals should enact institutional practices that affirm SGM and thereby deemphasize cisheteronormativity.

"Conversion Therapy" Experiences in Their Social Contexts: A Qualitative Study of Sexual Orientation and Gender Identity and Expression Change Efforts in Canada

OBJECTIVE

To describe in what forms, with whom, where, when, and why Canadians experience sexual orientation and gender identity and expression change efforts (SOGIECE).

METHODS

This qualitative study is grounded in a transformative paradigm. We conducted semi-structured interviews with a purposive sample of 22 adults recruited from across Canada who have experienced "conversion therapy." Directed content analysis was used, employing deductive and inductive coding approaches, to synthesize the findings and address 5 policy-relevant questions.

RESULTS

What are SOGIECE? Formal and informal methods of SOGIECE were used, including pharmacologic interventions, denial of gender-affirming care, and coaching to repress sexual orientation and/or gender identity and expression. With whom did SOGIECE occur? Practitioners included religious leaders, licenced health-care professionals (e.g., psychiatrists and psychologists), peers, and family members. Where did SOGIECE occur? SOGIECE occurred in 3 predominant settings: faith-based, health care, and social life. When did SOGIECE occur? SOGIECE rarely occurred over a restricted time frame; often, SOGIECE began while participants were adolescents or young adults and continued multiple years under various forms. Others described SOGIECE as a context in which their life was embedded for many years. Why did people attend SOGIECE? Cisheteronormative social and religious expectations taught participants that being non-cisgender or non-heterosexual was incompatible with living a good and respectable life.

CONCLUSIONS

SOGIECE are not a circumscribed set of practices. Our study shows that SOGIECE are a larger phenomenon that consists of intentional and explicit change efforts as well as heterosexual- and cisgender-dominant social norms expressed and enforced across a wide range of settings and circumstances. This study provides critical context to inform contemporary social and health policy responses to SOGIECE. Policies should account for the overt, covert, and insidious ways that SOGIECE operate in order to effectively promote safety, equity, and health for sexually diverse and gender-diverse people.

Minority stress and the inner critic/oppressive sociocultural schema mode among sexual and gender minorities

Several adverse psychological outcomes among sexual and gender minorities (SGM) are well documented in the literature. Notwithstanding the emergence of these data, SGM still receive little attention regarding psychological interventions, which include Schema Therapy (ST), an emerging integrative psychotherapy approach. Even though revisions have been proposed to expand ST’s understanding of emotional needs, schemas, domains, and schema modes, there is a gap in our understanding of SGM. Based on that, the main goal of this theoretical essay is to propose a specific ST intervention for SGM, addressing sociocultural aspects aiming at promoting a healthy functioning that can interpose oppression and internalized prejudice. To this end, we will present (a) the minority stress theoretical framework; (b) the ST model applying to SGM clients; and (c) a few strategies of ST intervention for SGM clients, highlighting the need for strengthening individuals’ healthy schema mode. It should be noted that, despite clinical work being relevant, there are social variables supporting and maintaining maladaptive structures. We hope the therapeutic interventions proposed promote dialogue on this subject and encouraging positive societal changes.

Sexual orientation and gender identity and expression conversion exposure and their correlates among LGBTQI2+ persons in Québec, Canada

Background

Despite greater acceptance of sexual and gender diversity and the scientific consensus that same-gender attraction, creative gender expression, and transness are not mental illnesses, LGBTQI2+ persons are still commonly told that they can or should change their sexual orientation, gender identity, or gender expression (SOGIE). The aim of this study was to describe the prevalence of SOGIE conversion efforts, including their sociodemographic correlates, among LGBTQI2+ persons.

Methods

Using community-based sampling, we assessed SOGIE conversion attempts and involvement in conversion services of 3,261 LGBTQI2+ persons aged 18 years and older in Quebec, Canada.

Results

A quarter of respondents experienced SOGIE conversion attempts, and fewer than 5% were involved in conversion services. Over half of those who were involved in SOGIE conversion services consented to them, but the services’ goals were made clear and explicit to only 55% and 30% of those who engaged in SO and GIE conversion, respectively. The results also suggest that family plays a key role in SOGIE conversion attempts and services utilization, and that indigenous, intersex, transgender, non-binary, and asexual persons, people of colour, as well as individuals whose sexual orientation is not monosexual (i.e., bisexual, pansexual) were more likely to have been exposed to conversion attempts and involved in conversion services.

Conclusions

This study found that the prevalence of conversion efforts is substantial. Interventions to protect LGBTQI2+ people from such attempts should focus not only on legal bans, but also on supporting families who need to be counseled in accepting sexual and gender diversity. Health professionals need to be adequately trained in LGBTQI2+ affirmative approaches. Religious therapists should consult with colleagues and undergo supervision to ensure that their religious beliefs do not interfere with their practice.