Associations of Suicide Attempts and Gender Identity Conversion Therapy Among Transgender and Non-Binary Individuals

Background and Purpose: Affirmation of gender identity is critical for mental and overall wellbeing of transgender and nonbinary (TNB) persons. Gender identity conversion efforts (GICE), an outlawed practice for licensed professionals in numerous U.S. jurisdictions, has been associated with exacerbated mental health and substance use outcomes. Limited previous literature examining GICE exposure and wellbeing has been criticized for failing to distinguish mental health outcomes for TNB persons before or after GICE. Our study builds on current literature by examining differences in TNB persons’ psychosocial risk indicators based on their GICE exposure, accounting for pre-GICE mental wellbeing.

Methods: We conducted a secondary data analysis using the 2015 U.S. Transgender Survey (N=25,810), the largest available national survey aimed at understanding TNB persons’ experiences. Using logistic regression models, we examined how GICE exposure (disaggregated by temporal precedence of suicide attempts) is related to psychological distress (Kessler-6), extra-medical prescription use, healthcare and public restroom avoidance, housing instability, incarceration, and intimate partner violence (IPV). Covariates included age, race, gender identity, sexual orientation, education, employment status, income, and (de)transitioning experiences. The average age of the participants was 31 with most participants identifying as transwomen (32.9%) and transmen (29.0%) followed by nonbinary participants. Regarding race, most identified as white (81.9%) followed by biracial (5.6%) and Latinx (5.3%) participants.

Results: GICE exposure was reported by 8.3% of the participants among whom 55.0% indicated suicide attempt initiation following GICE. Participants who first attempted suicide within the same year as GICE exposure were more likely to experience severe psychological distress (aOR=6.7), avoidance of doctors due to anticipation of disrespect (aOR=6.4), avoidance of bathrooms out of fear (aOR=6.1), emotional IPV (aOR=5.8), physical IPV (aOR=5.1), housing instability (aOR=7.8), and incarceration (aOR=9.9) relative to participants who experienced no GICE and no suicide (NGNS) (p>.001). Similarly, participants who attempted suicide for the first-time post-GICE were significantly more likely to engage in extra-medical use of prescription substances (aOR=2.3), and experience severe psychological distress (aOR=3.4), avoidance of doctors due to anticipation of disrespect (aOR=2.9) and bathrooms out of fear (aOR=1.9), emotional IPV (aOR=4.3), physical IPV (aOR=4.5), and housing instability (aOR=3.0) compared to the NGNS participants (p>.001).

Conclusions and Implications: Findings suggest those who attempted suicide for the first time within a year of or post-GICE exposure were at the highest risk for most outcomes. Although participants with a pre-GICE suicide attempt and those who attempted suicide without GICE exposure were also more likely to experience some poorer outcomes compared to NGNS, those who initiated suicide attempt post or within the same year of GICE had the highest risk profiles. While causality cannot be inferred, the temporal order of our findings suggests that GICE exposure may have a long-term detrimental role in many facets of TNB persons’ lives, especially for those who attempt suicide for the first time close to or post-GICE. Our findings provide further support for outlawing GICE, and for more research to better understand the mechanisms through which GICE exposure maybe associated with poorer wellbeing.