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Figure.
Mental Health Outcomes Among Those With and Without Exposure to Gender Identity Conversion Efforts
Mental Health Outcomes Among Those With and Without Exposure to Gender Identity Conversion Efforts

Raw frequencies for outcome variables among those with a lifetime history of non–gender identity conversion efforts therapy, lifetime history of exposure to gender identity conversion efforts, and exposure to conversion efforts before age 10 years. Severe psychological distress in the previous month was defined as a score of 13 or more on the Kessler Psychological Distress Scale, a cutoff that has been previously validated in US samples.17 Binge drinking was defined as at least 1 or more day of consuming 5 or more standard alcoholic drinks on the same occasion, a threshold for which the rationale in alcohol research among transgender people has been discussed in previous reports.18 Illicit drug use excludes marijuana use.

Table 1.  
Demographics of Participants With and Without Lifetime Exposure to Gender Identity Conversion Effortsa
Demographics of Participants With and Without Lifetime Exposure to Gender Identity Conversion Effortsa
Table 2.  
Outcomes for Those With Lifetime Exposure to Gender Identity Conversion Effortsa
Outcomes for Those With Lifetime Exposure to Gender Identity Conversion Effortsa
Table 3.  
Demographics of Those With and Without Childhood Exposure to Gender Identity Conversion Effortsa
Demographics of Those With and Without Childhood Exposure to Gender Identity Conversion Effortsa
Table 4.  
Outcomes for Those With Childhood Exposure to Gender Identity Conversion Effortsa
Outcomes for Those With Childhood Exposure to Gender Identity Conversion Effortsa
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Beckwith  N, McDowell  MJ, Reisner  SL,  et al.  Psychiatric epidemiology of transgender and nonbinary adult patients at an urban health center.  LGBT Health. 2019;6(2):51-61. doi:10.1089/lgbt.2018.0136PubMedGoogle ScholarCrossref
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Grant  JM, Mottet  LA, Tanis  J, Harrison  J, Herman  JL, Keisling  M.  Injustice at Every Turn: A Report of the National Transgender Discrimination Survey. Washington DC: National Center for Transgender Equality; 2011.
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Turban  JL, Ehrensaft  D.  Research review: gender identity in youth: treatment paradigms and controversies.  J Child Psychol Psychiatry. 2018:59(12):1228-1243. doi:10.1111/jcpp.12833PubMedGoogle Scholar
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Durwood  L, McLaughlin  KA, Olson  KR.  Mental health and self-worth in socially transitioned transgender youth.  J Am Acad Child Adolesc Psychiatry. 2017;56(2):116-123.e2. doi:10.1016/j.jaac.2016.10.016PubMedGoogle ScholarCrossref
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Byne  W.  Regulations restrict practice of conversion therapy.  LGBT Health. 2016;3(2):97-99. doi:10.1089/lgbt.2016.0015PubMedGoogle ScholarCrossref
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Byne  W, Bradley  SJ, Coleman  E,  et al; American Psychiatric Association Task Force on Treatment of Gender Identity Disorder.  Report of the American Psychiatric Association Task Force on treatment of gender identity disorder.  Arch Sex Behav. 2012;41(4):759-796. doi:10.1007/s10508-012-9975-xPubMedGoogle ScholarCrossref
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Rafferty  J; Committee on Psychosocial Aspects of Child and Family Health; Committee on Adolescence; Section on Lesbian, Gay, Bisexual, and Transgender Health and Wellness.  Ensuring comprehensive care and support for transgender and gender-diverse children and adolescents.  Pediatrics. 2018;142(4):e20182162. doi:10.1542/peds.2018-2162PubMedGoogle Scholar
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Salzman  J. Colorado’s Ban on “Conversion Therapy” Won’t Stop the Catholic Church. Rewire.News. Published January 28, 2019. https://rewire.news/article/2019/01/28/colorados-ban-on-conversion-therapy-wont-stop-the-catholic-church/. Accessed August 1, 2019.
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Drescher  J, Pula  J.  Ethical issues raised by the treatment of gender-variant prepubescent children.  Hastings Cent Rep. 2014;44(suppl 4):S17-S22. doi:10.1002/hast.365PubMedGoogle ScholarCrossref
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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.
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Herman-Giddens  ME, Steffes  J, Harris  D,  et al.  Secondary sexual characteristics in boys: data from the Pediatric Research in Office Settings Network.  Pediatrics. 2012;130(5):e1058-e1068. doi:10.1542/peds.2011-3291PubMedGoogle ScholarCrossref
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Herman-Giddens  ME, Slora  EJ, Wasserman  RC,  et al.  Secondary sexual characteristics and menses in young girls seen in office practice: a study from the Pediatric Research in Office Settings Network.  Pediatrics. 1997;99(4):505-512. doi:10.1542/peds.99.4.505PubMedGoogle ScholarCrossref
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Kessler  RC, Green  JG, Gruber  MJ,  et al.  Screening for serious mental illness in the general population with the K6 screening scale: results from the WHO World Mental Health (WMH) survey initiative.  Int J Methods Psychiatr Res. 2010;19(suppl 1):4-22. doi:10.1002/mpr.310PubMedGoogle ScholarCrossref
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Gilbert  PA, Pass  LE, Keuroghlian  AS, Greenfield  TK, Reisner  SL.  Alcohol research with transgender populations: a systematic review and recommendations to strengthen future studies.  Drug Alcohol Depend. 2018;186:138-146. doi:10.1016/j.drugalcdep.2018.01.016PubMedGoogle ScholarCrossref
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Sedgwick  P.  Multiple hypothesis testing and Bonferroni’s correction.  BMJ. 2014;349:g6284. doi:10.1136/bmj.g6284PubMedGoogle ScholarCrossref
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Bennett  DA.  How can I deal with missing data in my study?  Aust N Z J Public Health. 2001;25(5):464-469. doi:10.1111/j.1467-842X.2001.tb00294.xPubMedGoogle ScholarCrossref
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Mallory  C, Brown  TNT, Conron  KJ. Conversion therapy and LGBT youth. Published January 2018. Williams Institute, UCLA School of Law. https://williamsinstitute.law.ucla.edu/wp-content/uploads/Conversion-Therapy-LGBT-Youth-Jan-2018.pdf. Accessed August 1, 2019.
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DeLeon PH.  Appropriate therapeutic responses to sexual orientation. Proceedings of the American Psychological Association, Inc, for the legislative year 1997: minutes of the annual meeting of the Council of Representatives.  Am Psychol. 1998;53:882-939.Google ScholarCrossref
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Hatzenbuehler  ML.  How does sexual minority stigma “get under the skin”? a psychological mediation framework.  Psychol Bull. 2009;135(5):707-730. doi:10.1037/a0016441PubMedGoogle ScholarCrossref
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Meyer  IH, Brown  TN, Herman  JL, Reisner  SL, Bockting  WO.  Demographic characteristics and health status of transgender adults in select US regions: behavioral risk factor surveillance system, 2014.  Am J Public Health. 2017;107(4):582-589. doi:10.2105/AJPH.2016.303648PubMedGoogle ScholarCrossref
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Wallace  R, Russell  H.  Attachment and shame in gender–nonconforming children and their families: toward a theoretical framework for evaluating clinical interventions.  Int J Transgenderism. 2013;14(3):113-126. doi:10.1080/15532739.2013.824845Google ScholarCrossref
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Ryan  C, Russell  ST, Huebner  D, Diaz  R, Sanchez  J.  Family acceptance in adolescence and the health of LGBT young adults.  J Child Adolesc Psychiatr Nurs. 2010;23(4):205-213. doi:10.1111/j.1744-6171.2010.00246.xPubMedGoogle ScholarCrossref
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Bockting  WO, Miner  MH, Swinburne Romine  RE, Hamilton  A, Coleman  E.  Stigma, mental health, and resilience in an online sample of the US transgender population.  Am J Public Health. 2013;103(5):943-951. doi:10.2105/AJPH.2013.301241PubMedGoogle ScholarCrossref
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de Vries  AL, Steensma  TD, Cohen-Kettenis  PT, VanderLaan  DP, Zucker  KJ.  Poor peer relations predict parent- and self-reported behavioral and emotional problems of adolescents with gender dysphoria: a cross-national, cross-clinic comparative analysis.  Eur Child Adolesc Psychiatry. 2016;25(6):579-588. doi:10.1007/s00787-015-0764-7PubMedGoogle ScholarCrossref
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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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    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: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.

    Introduction

    Transgender persons are those whose sex assigned at birth differs from their gender identity, the inner sense of their own gender.1 According to a study by the Williams Institute,1 approximately 1.4 million (0.6%) adults in the United States identify as transgender. Transgender persons in the United States experience a disproportionately high prevalence of adverse mental health outcomes, including a 41% lifetime prevalence of self-reported suicide attempts.2-4

    Studies5-7 have shown that gender-affirming models of care are associated with positive mental health outcomes among transgender people. Gender identity conversion therapy refers to psychological interventions with a predetermined goal to change a person’s gender identity to align with their sex assigned at birth.8 Several US states have passed legislation banning conversion therapy for gender identity.8 Professional organizations including the American Medical Association,9 the American Psychiatric Association,10 the American Academy of Child & Adolescent Psychiatry,11 and the American Academy of Pediatrics12 have labeled the practice unethical and ineffective. Despite these policy statements, however, the question of whether to ban gender identity conversion therapy remains a contentious policy debate.

    State-level conversion therapy bans have been focused on gender identity conversion efforts (GICE) by licensed mental health practitioners. Nonlicensed religious advisors have also advertised GICE, and it is unknown whether GICE by these 2 groups of practitioners are distinct in their effects on mental health.13

    Because gender identity is thought to be stable after puberty for most transgender persons, few have supported use of GICE after pubertal onset.4 Some, however, have supported these efforts for prepubescent children, theorizing that gender identity may be more modifiable at this age.14 Increasingly, this approach has fallen out of favor, with the growing understanding that gender diversity is not a pathologic finding that requires modification.14 To our knowledge, there have been no studies evaluating the associations between exposure to GICE during either childhood or adulthood and adult mental health outcomes.

    The current study used the largest cross-sectional survey to date of transgender adults living in the United States to assess whether recalled lifetime exposure to GICE is associated with adverse mental health outcomes, including suicide attempts. The study also assessed whether recalled childhood exposure to GICE before the age of 10 years is associated with adverse mental health outcomes in adulthood. We hypothesized that there would be associations between exposure to GICE by both secular and religious professionals and worse mental health outcomes.

    Methods
    Study Design and Data Source

    The 2015 US Transgender Survey15 is a cross-sectional survey that was conducted by the National Center for Transgender Equality (NCTE) between August 19 and September 21, 2015. It is the largest existing survey of transgender adults and was distributed via community-based outreach.15 The US Transgender Survey protocol was reviewed and approved by the University of California Los Angeles institutional review board, Los Angeles, California. The US Transgender Survey data set was organized and recoded as described in the NCTE report on the survey.15 The protocol for the present study was reviewed by the Fenway Institute institutional review board and was determined not to comprise human subjects research. Data analysis was performed from June 8, 2018, to January 2, 2019.

    Study Population

    The data set includes responses from 27 715 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. The NCTE report on the survey further characterizes recruitment strategies and the sample of respondents.15 Because the organizations that conducted outreach for the survey did not systematically document the number of individuals reached by their outreach efforts, a response rate could not be calculated.

    Exposures

    The primary exposure of interest was an affirmative response to the binary survey question, “Did any professional (such as a psychologist, counselor, or religious advisor) try to make you identify only with your sex assigned at birth (in other words, try to stop you being trans)?” This recalled exposure is herein referred to as GICE. Endorsement of lifetime exposure to GICE was examined among all those who confirmed having spoken to a professional about gender identity. Outcomes were compared among respondents who reported exposure to GICE before the age of 10 years with outcomes among those who endorsed lifetime exposure to therapy without GICE. Because the data set does not contain age of exposure to non-GICE therapy, participants with any lifetime exposure to non-GICE therapy were selected as the reference group in the analysis of those exposed to GICE before age 10 years. As data regarding ages of pubertal onset among respondents were not available, younger than 10 years was used as a cutoff to approximate a prepubertal population, with the understanding that there is significant individual variability in the age at onset of puberty.16,17 Furthermore, we examined whether there was a difference in outcomes between those who reported exposure to GICE from a secular professional compared with those who reported exposure to GICE from a religious advisor.

    Outcomes

    We compared respondents with and without recalled exposure to GICE with regard to the following binary mental health variables: severe psychological distress during the previous month (defined as a score of ≥13 on the Kessler Psychological Distress Scale, a cutoff that has been previously validated in US samples18); binge drinking during the previous month (defined as ≥1 day of consuming ≥5 standard alcoholic drinks on the same occasion, a threshold for which the rationale in alcohol research among transgender persons has been discussed in previous reports19); lifetime cigarette and illicit drug use (not including marijuana); suicidal ideation during the previous year; suicidal ideation with plan during the previous year; suicide attempt during the previous year; suicide attempt requiring inpatient hospitalization during the previous year; lifetime suicidal ideation; and lifetime number of suicide attempts (0, 1, or ≥2).

    Control Variables

    Demographic and socioeconomic variables were collected and analyzed as defined in the US Transgender Survey, including sex assigned at birth, present gender identity, sexual orientation, racial/ethnic identity according to the recoded NCTE categories reflecting those typically reported in the American Community Survey, age (both in integer form and using US census categories to capture cohort effects), family support of gender identity, relationship status (with partnered coded by these authors as binary and inclusive of both open and polyamorous relationships), educational achievement, employment status, and total household income. In supplemental analyses, we also controlled for exposure to sexual orientation conversion efforts undertaken by professionals.

    Statistical Analysis

    Analyses were conducted using SAS Studio, version 3.71, Basic Edition (SAS Institute). Participants were excluded from analyses if they did not report ever discussing their gender identity with a professional. Control variables were treated as unordered classification variables. Using the sample weights generated by the NCTE15 to improve generalizability by addressing sampling biases around age, educational level, and race/ethnicity, we generated descriptive statistics for control and outcome variables. Bivariate analyses comparing responses from transgender adults were conducted based on (1) whether or not they had any lifetime exposure to GICE, (2) whether they had experienced GICE before age 10 years vs never, and (3) whether GICE were conducted by a secular vs religious professional. These bivariate analyses were performed to detect potential confounders to control for in subsequent regression analysis. Except for age, all variables were categorical; thus, we used Rao-Scott χ2 tests for design-adjusted data with 1 df for bivariate comparisons. Age as an integer variable was nonnormally distributed; thus, bivariate comparison was performed with the nonparametric Mann-Whitney test. Standard errors and 95% CIs were calculated for the prevalence estimates of exposure to GICE using the aforementioned 1.4 million persons as the total population estimate.1

    Multivariable logistic regression models were conducted to test whether GICE were associated with the outcomes, adjusted for variables with significant differences between groups in the preceding bivariate analyses. These models also used survey weights generated by the NCTE for age, educational level, and race/ethnicity. Adjusted odds ratios (aORs) with 95% CIs and 2-sided P values were reported, with a P < .001 threshold for significance.

    Approximately 66 comparisons (between bivariate tests and logistic regression models) were made in each analysis. To reduce risk of type I error, a modified Bonferroni correction for multiple comparisons was performed, with resulting α = .001 (ie, .05 divided by 50). Using the full number of comparisons yields only a slightly lower α = .0008, which ultimately would not have altered the findings. We therefore selected an α = .001 for both ease of reading and also the statistical consensus that unmodified Bonferroni correction tends to be maximally conservative, thereby unnecessarily inflating type II error.20 Thus, hypothesis tests were 2-sided with corrected significance level P < .001 for both primary and secondary analyses, and the 95% CIs reported reflect this correction.

    Respondents with missing data for exposure and outcome variables comprised less than 2% of the analytic samples and were therefore excluded without compensatory methods, as is widely considered acceptable for this degree of data completeness.21 Data were missing for less than 9% of each control variable, thereby obviating the need for imputation, which can introduce bias, especially when data are nonrandomly missing. There is debate about the degree of incompleteness that is acceptable without compensatory measures, and although individuals with incomplete data may be of particular interest, thresholds for missingness as high as 10% are considered to be acceptable.22

    Results

    Of the 27 715 US Transgender Survey respondents (mean [SD] age, 31.2 [13.5] years), 11 857 (42.8%) were assigned male sex at birth, and 3869 (14.0%; 95% CI, 13.3%-14.7%) reported exposure to GICE. Of 19 751 respondents who had discussed their gender identity with a professional, 3869 (19.6%; 95% CI, 18.7%-20.5%) reported exposure to GICE in their lifetime. Of these individuals, 1361 (35.2%; 95% CI, 32.7%-37.7%) who reported exposure to GICE stated that these were enacted by a religious advisor.

    Demographic variables among exposed and unexposed respondents are shown in Table 1. 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 (aOR, 1.56; 95% CI, 1.09-2.24; P < .001) and lifetime suicide attempts (aOR, 2.27; 95% CI, 1.60-3.24; P < .001). (Table 2).

    Overall, 206 (1.0%; 95% CI, 0.8%-1.2%) of those who reported discussing their gender identity with a professional also reported exposure to GICE before age 10 years. Demographics are shown in Table 3. After adjusting for statistically significant demographic variables, exposure to GICE before age 10 years was significantly associated with several measures of suicidality, including lifetime suicide attempts (aOR, 4.15; 95% CI, 2.44-7.69; P < .001) (Table 4).

    Raw frequencies of outcome variables among exposure groups are shown in the Figure. There were no statistically significant differences in outcomes between those who were exposed to GICE enacted by religious advisors and those exposed to GICE by secular professionals (all aOR, P > .001) (eTable 1 and eTable 2 in the Supplement).

    We also repeated all analyses adjusting for lifetime exposure to sexual orientation conversion efforts, defined as a positive response to the survey question, “Did any professional (such as a psychologist, counselor, or religious advisor) ever try to change your sexual orientation or who you are attracted to (such as try to make you straight or heterosexual)?” After this adjustment, both lifetime exposure (aOR, 1.96; 95% CI, 1.38-2.80; P < .001) and childhood exposure (aOR, 3.05; 95% CI, 1.55-6.02; P < .001) to GICE were associated with increased odds of lifetime suicide attempts but not with the other outcome variables (eTables 3 and 4 in the Supplement). Because this question was unclear regarding the referent gender (sex assigned at birth vs gender identity) when defining sexual orientation conversion efforts, we refer to the models not adjusted for this variable throughout the article.

    Discussion

    This study was the first, to our knowledge, to show an association between exposure to GICE (lifetime and childhood) and adverse mental health outcomes among transgender adults in the United States. We found that recalled lifetime exposure to GICE was highly prevalent among adults: 14.0% of all transgender survey respondents and 19.6% of those who had discussed gender identity with a professional reported exposure to GICE.

    The Generations Study23 by the Williams Institute found that 6.7% of sexual minority group adults in the United States reported lifetime exposure to conversion efforts for sexual orientation.23 Based on the findings of the current study, it appears that transgender people are exposed to GICE at high rates, perhaps even higher than the percentage of cisgender nonheterosexual individuals who are exposed to sexual orientation conversion efforts, although direct comparisons are not possible. One potential explanation for this is that compared with persons in the sexual minority group, many persons in the gender minority group must interact with clinical professionals to be medically and surgically affirmed in their identities. This higher prevalence of interactions with clinical professionals among people in the gender minority group may lead to greater risk of experiencing conversion efforts.

    One study24 showed that conversion efforts for sexual orientation were associated with an increased risk of depression and suicidal ideation. The current study was the first, to our knowledge, to find associations between any type of conversion efforts and both suicidal ideation and suicide attempts. A plausible association of these practices with poor mental health outcomes can be conceptualized through the minority stress framework; that is, elevated stigma-related stress from exposure to GICE may increase general emotion dysregulation, interpersonal dysfunction, and maladaptive cognitions.25 Of note, having a lifetime suicide attempt was a more common outcome compared with severe psychological distress during the previous month, a result that was likely attributable to the time frames during which these variables were defined. Although this study suggests that exposure to GICE is associated with increased odds of suicide attempts, GICE are not the only way in which minority group stress manifests, and thus other factors are also likely to be associated with suicidality among gender-diverse people.

    Respondents from more socioeconomically disadvantaged backgrounds (eg, low educational attainment or low household income) more commonly reported exposure to GICE. These individuals may have been more likely to receive GICE, or exposure to GICE may have been so damaging that they were impaired in educational, professional, and economic advancement. The cross-sectional nature of this study limits further interpretation. This finding warrants additional attention in the context of nationally representative data showing lower educational attainment and lower income among transgender people in the United States compared with their cisgender counterparts.26

    Given the considerable debate surrounding the merits of GICE for prepubertal youth,4 we examined recalled early exposure to GICE (ie, before age 10 years) and found this to be less prevalent, with 1% of those who had ever discussed gender identity with a professional reporting that they had been exposed before age 10 years. Many experts have expressed concern that early exposure to GICE may lead to persistent feelings of shame because of physicians and parents defining gender-expansive experience as unacceptable.4 A study27 in Canada found a higher prevalence of shame-related feelings among youth treated with GICE. Both family and peer rejection of a child’s gender identity have been associated with adverse mental health outcomes.27-30 Extending those findings, the current study showed that recalled early exposure to GICE was associated with adverse mental health outcomes, including lifetime suicide attempts, compared with discussion of gender identity with a professional and no exposure to conversion efforts. Although not compared directly, the aOR of lifetime suicide attempts was higher for those exposed to GICE before age 10 years than the aOR for those with lifetime exposure, suggesting that rejection of gender identity may have more profound consequences at earlier stages of development. Further research is needed to better understand the associations between stage of development at time of exposure to GICE and risk of lifetime suicide attempts.

    Our results support the policy positions of the American Academy of Child and Adolescent Psychiatry,11 the American Psychiatric Association,10 the American Academy of Pediatrics,12 and the American Medical Association,9 which state that gender identity conversion therapy should not be conducted for transgender patients at any age. Our finding of no difference in mental health outcomes between respondents who received GICE from a secular-type professional and those who received it from a religious advisor suggests that 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.

    Strengths and Limitations

    Strengths of this study include its sample size, more than 90% completeness in the data set, and participants from a wide geographic area within the United States. Limitations include its cross-sectional study design, which precludes determination of causation. It is possible that those with worse mental health or internalized transphobia may have been more likely to seek out conversion therapy rather than non-GICE therapy, suggesting that conversion efforts themselves were not causative of these poor mental health outcomes. This interpretation, however, would also imply a mechanism whereby societal rejection leads to internalized transphobia and life-threatening adult mental health outcomes.

    We also lack data regarding the degree to which GICE occurred (eg, duration, frequency, and forcefulness of GICE, as well as what specific modalities were used). If a sizable proportion of those reporting exposure to GICE in the current study experienced relatively mild or infrequent conversion efforts, this might suggest the findings of this study are even more concerning (ie, even mild or infrequent conversion efforts were associated with adverse mental health outcomes, including suicide attempts). Because the survey question asked about exposure to GICE from professionals, it is possible that exposures to GICE from other people (eg, family members) were not captured. Although the survey included respondents from a wide geographic distribution across the United States, these participants were not recruited via random sampling. The sample may not be nationally representative. Data are also lacking regarding when respondents entered puberty, making it difficult to define a prepubertal sample; we therefore set an approximate prepubertal cutoff at age 10 years. In this study, we compared exposure to GICE before age 10 years with lifetime exposure to non-GICE therapy. Although it would have been ideal to compare the former group with those who experienced non-GICE therapy before age 10 years, we lacked data on the age at which respondents were exposed to non-GICE therapy.

    Conclusions

    The findings suggest that recalled exposure to GICE is associated with adverse mental health outcomes in adulthood, including severe psychological distress, lifetime suicidal ideation, and lifetime suicide attempts. In this study, exposure to GICE before age 10 years was associated with adverse mental health outcomes compared with therapy without conversion efforts. Results from this study support past positions taken by leading professional organizations that GICE should be avoided with children and adults.

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    Article Information

    Accepted for Publication: June 17, 2019.

    Corresponding Author: Jack L. Turban, MD, MHS, Division of Child and Adolescent Psychiatry, Massachusetts General Hospital, Adult OPC, Mailstop 229, 115 Mill St, Belmont, MA 02478 (jack.turban@mgh.harvard.edu).

    Published Online: September 11, 2019. doi:10.1001/jamapsychiatry.2019.2285

    Author Contributions: Dr Beckwith had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: All authors.

    Acquisition, analysis, or interpretation of data: All authors.

    Drafting of the manuscript: Turban, Beckwith, Keuroghlian.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Beckwith, Reisner.

    Obtained funding: Reisner, Keuroghlian.

    Administrative, technical, or material support: Turban, Keuroghlian.

    Supervision: Reisner, Keuroghlian.

    Conflict of Interest Disclosures: Dr Turban reported collecting royalties from Springer for an upcoming textbook about pediatric gender identity. No other disclosures were reported.

    Funding/Support: This work was supported by grant U30CS22742 from the Health Resources and Services Administration Bureau of Primary Health Care (Dr Keuroghlian), partly supported by a grant from the National Institutes of Health under award number UG3AI133669 (Dr Reisner), and an American Academy of Child and Adolescent Psychiatry Pilot Research Award for General Psychiatry Residents (Dr Turban).

    Role of the Funder/Sponsor: The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the Health Resources and Services Administration, the National Institutes of Health, or the American Academy of Child & Adolescent Psychiatry.

    Meeting Presentation: This paper was presented at the Annual Meeting of the American Academy of Child and Adolescent Psychiatry; October 25, 2018; Seattle, Washington.

    Additional Contributions: We thank the National Center for Transgender Equality for sharing the data from the 2015 US Transgender Survey.

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