Gender Identity Conversion Efforts at Any Age Are Associated with Suicidality Among Transgender Adults

Approximately 1.4 million adults in the United States identify as transgender, meaning their gender identity is different from the sex assigned to them at birth. Transgender children and adults are sometimes given or offered gender identity conversion therapy, defined as psychological interventions that have the predetermined goal of changing the client's gender identity to align with their sex assigned at birth.

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There is a growing understanding that transgender identity is not a pathology requiring modification, and gender identity conversion therapy has fallen out of favor. The American Medical Association, the American Psychiatric Association, the American Academy of Child and Adolescent Psychiatry and the American Academy of Pediatrics all label it unethical and ineffective and state that it should not be conducted with children or adults. In addition, several states have passed legislation banning it.

Nevertheless, some licensed mental health practitioners and unlicensed religious advisors continue to conduct gender identity conversion therapy, and the question of whether to ban it remains controversial in some U.S. states.

Jack Turban, MD, MHS, a resident in the Child and Adolescent Psychiatry Residency at Massachusetts General Hospital, Alex S. Keuroghlian, MD, MPH, director of the Massachusetts General Hospital Psychiatry Gender Identity Program in the Department of Psychiatry, and colleagues recently conducted the first study of its kind to evaluate the psychiatric consequences of gender identity conversion efforts. In JAMA Psychiatry, they report that transgender people exposed to such efforts at any age have increased odds of attempting suicide and other adverse mental health outcomes in adulthood.

Study Participants

The researchers drew on the 2015 U.S. Transgender Survey, conducted by the National Center for Transgender Equality via community-based outreach, which is the largest cross-sectional survey of transgender adults in the U.S. It includes participants from all 50 states, plus the District of Columbia, American Samoa, Guam, Puerto Rico and U.S. military bases overseas. Of the 27,715 respondents, 57% were assigned female sex at birth and 43% were assigned male sex.

As part of the survey, people who confirmed having spoken to a professional about gender identity were asked, "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)?" People who replied affirmatively were said to have been exposed to gender identity conversion efforts (GICE).

Prevalence of Conversion Efforts

3,869 survey respondents reported exposure to GICE, representing 14% of all respondents and 20% of those who had discussed their gender identity with a professional. Thirty-five percent of those exposed said GICE was initiated by a religious advisor.

Conversion Efforts and Mental Health

Compared with respondents who discussed gender identity with a professional without being exposed to conversion efforts, those exposed to GICE showed significantly higher odds of certain adverse mental health outcomes in adulthood:

• Suicidality in the past 12 months — suicide ideation (OR, 1.44); suicide ideation with a plan (OR, 1.52)
• Suicidality at any previous time — suicide ideation (OR, 1.9); one or more suicide attempts (OR, 2.27)
• Severe psychological distress during the previous month — score ≥13 on the Kessler Psychological Distress Scale (OR, 1.56)

There were no statistically significant differences in outcomes between respondents exposed to GICE by religious advisors and those exposed by secular professionals.

Conversion Efforts Before Age 10

206 respondents (1% of those exposed to who had ever spoken to a professional about their gender identity) reported exposure to GICE before age 10. Among adults, childhood exposure to GICE was significantly associated with:

• Suicidality in the past 12 months — suicide ideation (OR, 2.03); suicide ideation with a plan (OR, 2.82)
• Suicidality at any previous time — one or more suicide attempts (OR, 4.15)

Interpreting the Findings

The sexual minority stress framework in psychology, adapted by Michael L. Hendricks of Washington Psychological Center, P.C., and Rylan J. Testa, PhD, and published in Professional Psychology: Research & Practice, proposes that sexual minorities confront increased stress resulting from stigma, which leads to emotional, social/interpersonal and cognitive problems that confer risk of psychopathology. This framework is a plausible explanation of why gender identity conversion therapy is associated with poor mental health outcomes.

Many transgender people must interact with health care professionals in order to be medically and surgically affirmed in their identities. The results of this study and the policy statements of several professional organizations emphasize the importance of refraining from gender identity conversion efforts, and specifically, efforts aimed at a child under 10 that seem to have particularly negative consequences.

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Learn more about the Transgender Health Program at Mass General

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