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Original Investigation
September 11, 2019

Association Between Recalled Exposure to Gender Identity Conversion Efforts and Psychological Distress and Suicide Attempts Among Transgender Adults

Author Affiliations
  • 1Division of Child and Adolescent Psychiatry, Massachusetts General Hospital, Boston
  • 2Department of Psychiatry, Massachusetts General Hospital, Boston
  • 3Department of Pediatrics, Harvard Medical School and Boston Children’s Hospital, Boston, Massachusetts
  • 4Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
  • 5Department of Psychiatry, Harvard Medical School, and Massachusetts General Hospital, Boston
  • 6The Fenway Institute, Boston, Massachusetts
JAMA Psychiatry. Published online September 11, 2019. doi:https://doi.org/10.1001/jamapsychiatry.2019.2285
Key Points

Question  Is recalled exposure to gender identity conversion efforts (ie, psychological interventions that attempt to change one’s gender identity from transgender to cisgender) associated with adverse mental health outcomes in adulthood?

Findings  In a cross-sectional study of 27 715 US transgender adults, recalled exposure to gender identity conversion efforts was significantly associated with increased odds of severe psychological distress during the previous month and lifetime suicide attempts compared with transgender adults who had discussed gender identity with a professional but who were not exposed to conversion efforts. For transgender adults who recalled gender identity conversion efforts before age 10 years, exposure was significantly associated with an increase in the lifetime odds of suicide attempts.

Meaning  The findings suggest that lifetime and childhood exposure to gender identity conversion efforts are associated with adverse mental health outcomes.

Abstract

Importance  Gender identity conversion efforts (GICE) have been widely debated as potentially damaging treatment approaches for transgender persons. The association of GICE with mental health outcomes, however, remains largely unknown.

Objective  To evaluate associations between recalled exposure to GICE (by a secular or religious professional) and adult mental health outcomes.

Design, Setting, and Participants  In this cross-sectional study, a survey was distributed through community-based outreach to transgender adults residing in the United States, with representation from all 50 states, the District of Columbia, American Samoa, Guam, Puerto Rico, and US military bases overseas. Data collection occurred during 34 days between August 19 and September 21, 2015. Data analysis was performed from June 8, 2018, to January 2, 2019.

Exposure  Recalled exposure to GICE.

Main Outcomes and Measures  Severe psychological distress during the previous month, measured by the Kessler Psychological Distress Scale (defined as a score ≥13). Measures of suicidality during the previous year and lifetime, including ideation, attempts, and attempts requiring inpatient hospitalization.

Results  Of 27 715 transgender survey respondents (mean [SD] age, 31.2 [13.5] years), 11 857 (42.8%) were assigned male sex at birth. Among the 19 741 (71.3%) who had ever spoken to a professional about their gender identity, 3869 (19.6%; 95% CI, 18.7%-20.5%) reported exposure to GICE in their lifetime. Recalled lifetime exposure was associated with severe psychological distress during the previous month (adjusted odds ratio [aOR], 1.56; 95% CI, 1.09-2.24; P < .001) compared with non-GICE therapy. Associations were found between recalled lifetime exposure and higher odds of lifetime suicide attempts (aOR, 2.27; 95% CI, 1.60-3.24; P < .001) and recalled exposure before the age of 10 years and increased odds of lifetime suicide attempts (aOR, 4.15; 95% CI, 2.44-7.69; P < .001). No significant differences were found when comparing exposure to GICE by secular professionals vs religious advisors.

Conclusions and Relevance  The findings suggest that lifetime and childhood exposure to GICE are associated with adverse mental health outcomes in adulthood. These results support policy statements from several professional organizations that have discouraged this practice.

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    3 Comments for this article
    EXPAND ALL
    Not all therapy is conversion therapy
    Julia Mason, M.S. M.D. | Calcagno Pediatrics
    As a pediatrician, I am very concerned with the probability that we are prematurely and permanently medicalizing many young patients who suffer from transient gender dysphoria (GD).

    Multiple studies confirm that only a small minority (15%) of childhood-onset GD persist; GD persistence may be even lower in the novel segment of adolescent-onset GD--a poorly understood group of primarily female patients, which has become the predominant presentation in the last 10 years.

    Many of these patients’ distress has resolved with the help of ethical forms of non-affirmative therapy, which allowed them to ascertain the reasons underlying their
    GD. Conversely, a great many have been harmed by quick affirmation, which often led to hormonal and surgical interventions they later regretted. (https://www.piqueresproject.com; https://www.reddit.com/r/detrans/)

    Turban et al allowed a number of study limitations-- including convenience sampling and failure to control for mental illness, a key predictor of suicidality--which should make any savvy reader wary of accepting the study conclusions about the harms of therapy aimed at alleviating GD.

    In addition, the authors failed to mention a key methodological flaw. The researchers limited their survey to a sample of persons identifying as transgender (a term that lacks clinical specificity), rather than including all persons who have suffered from gender dysphoria (a DSM 5 diagnosis). As a result, the study is not generalizable to the larger population of persons with gender dysphoria (GD). The number of persons who at one point suffered from GD but no longer do far outnumbers those who have persistent and consistent GD and thus identify as transgender.

    Without access to ethical exploratory psychotherapy (which the authors appear to incorrectly conflate with unethical conversion therapy), patients suffering from GD have only one option: permanent treatment with hormones and surgical interventions. Given the many known, and as yet-to-be discovered risks of puberty blockers and cross-sex hormones, the irreversibility of sex change surgeries, and the increasing numbers of young people expressing regret about choices made during what turned out to be a transient phase of their identity formation, it’s critical to ensure free access to all ethical forms of therapy.
    CONFLICT OF INTEREST: None Reported
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    A deeply flawed analysis
    Hacsi Horvath, MA | Department of Epidemiology and Biostatistics, University of California, San Francisco
    It is surprising that so eminent a scholar as Dr. Turban did not perceive the methodological errors to which he was evidently susceptible in preparing his recent analysis of suicidality in transgender persons [1]. Turban and colleagues [1] set out to find an association between what they call “gender identity conversion efforts” and suicide attempts later in life. "Gender identity conversion efforts" could perhaps be more clearly defined as any psychotherapeutic approach to helping patients begin to identify again with their own sexed bodies, without need of transgender medical intervention; or even any therapy that does not explicitly "affirm" patients' dysphoric feelings as evidence of transgender status.

    Turban and colleagues [1] examined data from a large 2015 survey of transgender persons in the United States[2]. Interestingly, the main findings reported by Turban and colleagues [1] were previously reported in the survey's published materials [2]. The respondent population in this survey was developed through convenience sampling, a method that may be appropriate for initial, exploratory research, but is inappropriate for research that aims to characterize health and illness in the entire population of interest. Turban and colleagues [1] suggest that the large size of the sample is a “strength” of their study, but they do not reflect on the sampling method’s inadequacy. It is very unlikely, for example, that the survey reached the population whose earlier gender dysphoria was alleviated through cognitive behavioral therapy or other standard approaches.

    It is widely known that data derived from convenience samples are inappropriate to use in making statistical estimates and generalizations about the overall population [3-5]. Estimates derived from such data are highly biased and are likely to be well off the mark. Data collected from survey respondents recruited at transgender-focused community events, web sites of transgender interest and other “convenient” settings are relevant only to the populations surveyed in these settings, at the time of the survey. Convenience sample data should certainly never underpin what appear to be firm study conclusions, which may influence health policy and increase the risk of iatrogenic harms in children, adolescents and adults who believe themselves to be transgender.

    References:

    1. Turban JL, Beckwith N, Reisner SL, Keuroghlian AS. Association Between Recalled Exposure to Gender Identity Conversion Efforts and Psychological Distress and Suicide Attempts Among Transgender Adults. JAMA Psychiatry. 2019 Sep 11:1-9.
    2. James SE, Herman JL, Rankin S, Keisling M, Mottet L, Anafi M. The Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality; 2016.
    3. Handbook of Survey Methodology for the Social Sciences. Lior Gideon, ed. New York: Springer; 2012.
    4. Fowler FJ. Survey Research Methods (5th edition). London: Sage Publications; 2013.
    5. Handbook of Health Survey Methods. Timothy Johnson, ed. Hoboken: John Wiley & Sons; 2015.
    CONFLICT OF INTEREST: None Reported
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    Misinterpretation of the findings of this study may limit safe, ethical treatment options for gender-questioning and gender-diverse people
    Richard Byng, MBBCh MPH PhD | University of Plymouth
    Prof Richard Byng, PhD, University of Plymouth, UK
    William J Malone, MD St. Luke’s Endocrinology and Diabetes Clinic, Twin Falls, ID.
    Prof David Curtis, PhD, Queen Mary University of London, UK

    The study by Turban and colleagues reports that previous exposure to “gender identity conversion efforts (GICE)” is associated with suicidality among transgender-identifying adults. While the large sample size is a strength, the authors underplay the serious methodological weaknesses, particularly the likely confounding effects of co-existing mental health problems. They then take this association and in the abstract and conclusion seek to imply causation. Hence, the findings could mislead
    frontline clinicians and public policymakers alike.

    The key limitation is that the study did not control for comorbid psychiatric illness, the greatest single predictor of suicidality. While mental health conditions are acknowledged as confounders, they are declared unlikely based on the spurious idea that this would require internalized transphobia. Rather, it seems likely that professionals encountering persons with gender dysphoria (GD) and significant mental health problems were more likely to engage in conversations about the merits of transition, which may later be recalled as a conversion effort. Thus, the association found is arguably more likely due to reverse causation.

    Another limitation is that the study data are from a convenience sample of current transgender-identifying individuals, rather than all persons with a history of GD. The sample is highly unlikely to have captured individuals exposed to GICE who subsequently adopted a gender identity concordant with their biological sex. Thus, these data cannot be generalized to individuals as they present with GD.

    Prepubertal-onset GD has a high rate of remission, while desistance of GD among those in adolescence with recent onset GD, the increasingly dominant presentation, is as yet unknown. We oppose coercive or unwanted deliberate attempts to change an individual’s gender identity and propose that a range of neutrally framed, supportive therapies and consultative approaches, which are neither affirmation nor conversion, be evaluated in randomized controlled trials. Outcomes of noninvasive treatments should be compared to those of “gender-affirmative models of care,” entailing hormonal and surgical interventions which are associated with increased heart disease, impairments in bone density, infertility, and high rates of suicide over the long term.

    References
    1. Turban J, et al. Association Between Recalled Exposure to Gender Identity Conversion Efforts and Psychological Distress and Suicide Attempts Among Transgender Adults. JAMA Psychiatry. 2019:1. doi:10.1001/jamapsychiatry.2019.2285
    2. Franklin J, et al. Risk factors for suicidal thoughts and behaviors: A meta-analysis of 50 years of research. Psychol Bull. 2017;143(2):187-232. doi:10.1037/bul0000084
    3. Steensma T, et al. Factors Associated With Desistence and Persistence of Childhood Gender Dysphoria: A Quantitative Follow-Up Study. Journal of the American Academy of Child & Adolescent Psychiatry. 2013;52(6):582-590. doi:10.1016/j.jaac.2013.03.016
    4. Dhejne C, et al. Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden. PLoS ONE. 2011;6(2):e16885. doi:10.1371/journal.pone.0016885
    CONFLICT OF INTEREST: None Reported
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