Abstract
Purpose:
Gender identity change efforts (GICEs), sometimes referred to as “conversion therapy,” are considered pseudoscientific and unethical practices that are not supported by the existing scientific literature. However, a substantial portion of transgender people face such practices during their lives. We assessed lifetime exposure to GICEs and its associations with mental health indicators among transgender adults in South Korea.
Methods:
We analyzed a nationwide cross-sectional survey of 566 Korean transgender adults conducted in October 2020. Lifetime exposure to GICEs was classified as follows: “never had GICE-related experiences,” “received a referral, but did not undergo GICEs,” and “undergone GICEs.” We assessed mental health indicators, including past-week depressive symptoms; medical diagnosis or treatment of depression and panic disorder; and past 12-month suicidal ideation, suicide attempts, and self-harm.
Results:
Of the total participants, 12.2% had “received a referral, but did not undergo GICEs,” and 11.5% had “undergone GICEs.” Compared with those who had “never had GICE-related experiences,” participants who had “undergone GICEs” showed significantly higher prevalence of depression (adjusted prevalence ratio [aPR]=1.34, 95% confidence interval [CI]=1.11–1.61), panic disorder (aPR=2.52, 95% CI=1.75–3.64), and suicide attempts (aPR=1.73, 95% CI=1.10–2.72). However, we did not find significant associations between having “received a referral, but did not undergo GICEs” and mental health indicators.
Conclusion:
Given our findings suggest that lifetime exposure to GICEs may harm transgender adults' mental health, legal restrictions should be imposed to ban GICEs in South Korea.
Keywords: conversion therapy, gender identity change efforts, mental health, South Korea, transgender persons
Introduction
Transgender people are those whose gender identity and/or expression differs from the sex they were assigned at birth.1 Gender identity change efforts (GICEs), so-called “conversion therapy,” are practices that attempt to change a person's gender identity to conform with their assigned sex at birth and thus force transgender people to live as cisgender people.2
A substantial portion of transgender people across the world face GICEs during their lives. In a study using the 2015 U.S. Transgender Survey, 13.5% of the total adult participants (N=27,676) reported lifetime exposure to GICEs.3 The proportion of transgender people who have experienced GICEs may vary with sociodemographic characteristics and cultural backgrounds. Particularly, it has been reported that children and adolescents are vulnerable to being subjected to such practices.2 In addition, GICEs have been implemented in a variety of settings, including counseling agencies, health care centers, and faith-based sites.2,4
GICEs are considered pseudoscientific and unethical practices that are not supported by the existing scientific literature.2,5,6 Furthermore, there is emerging evidence that GICEs can have a harmful impact on transgender people's wellbeing and health.2,5,6 Transgender people who have undergone GICE tend to report shame and self-hatred and experience isolation from social relationships, including their family and transgender communities.2,5 Previous studies also found that GICEs may increase risks of mental health outcomes (e.g., depression and suicidality) and health risk behaviors (e.g., smoking and excess alcohol drinking),2,5,7,8 which may contribute to health disparities among transgender people.9
Given the harmful impact of GICE on transgender people's wellbeing and health, international and national professional bodies (e.g., the United Nations and the American Psychological Association) have declared that GICEs should be outlawed.2,5,10 In many countries, national (e.g., Ecuador and Malta) and local (e.g., Canada and the United States) governments have also introduced legislation to ban GICEs.2,11 However, no national-level efforts have yet been made to prohibit sexual orientation and gender identity change efforts (SOGICEs) in South Korea (hereafter, Korea). Recently, the Korean Counseling Psychological Association permanently expelled a member for engaging in sexual orientation change efforts (SOCEs).12
The gender minority stress and resilience (GMSR) model, based on the existing model of sexual minority stress,13 explains how gender-related stressors contribute to the health disparities of transgender people above and beyond general stressors.14 Gender-related stressors include discrimination and victimization based on transgender identity, nonaffirmation of transgender identity, and internalized transphobia.14 A growing body of literature describes how transgender people in Korea experience gender-related stressors in the societal domains of education, employment, health care, and public facilities (e.g., bathrooms) in their daily lives.15–18 For example, a large community survey shows that 65.3% of Korean transgender adults experienced discrimination based on transgender identity or gender expression within the last 12 months.18
Hostile public attitudes toward transgender people and the lack of legal protection against discrimination based on gender identity and/or expression (e.g., comprehensive antidiscrimination laws) in Korea render transgender people vulnerable to discrimination and concomitant mental health risks.15,19,20 A previous study has documented substantial mental health disparities that Korean transgender adults faced.21 Specifically, transgender participants have more than six times higher prevalence of past 12-month suicidal ideation compared with the Korean general population.21
Specifically, GICEs represent an extreme form of gender-related stressor, as such practices are carried out under the premise that being transgender requires correction and aim to deny or erase the existence as a transgender person. Gender affirmation is a key determinant of transgender health and health care, referring to a process in which transgender people are fully recognized and accepted as who they are.22 Researchers have described GICEs as the antithesis of affirmation of a transgender person's gender identity.5
In Korea, it is difficult for transgender people to live as who they are regardless of their gender identity, and some of them even experience GICEs. According to a study by the Network for the Elimination of Conversion Therapy, 2.6% (N=28) of 1,072 Korean LGBT participants had ever experienced SOGICEs in their lifetime.23 In the same study, 35.7% (N=10) of the participants who experienced SOGICEs were self-identified as transgender people.23 However, to date, no known research has been conducted in Korea to quantify how many transgender people are exclusively exposed to GICEs and to examine the impact of GICEs on transgender health.
Using the largest survey of transgender people ever conducted in Korea, the current study aimed to assess lifetime exposure to GICEs among Korean transgender adults and investigate the association of GICEs with mental health indicators, including medically diagnosed or treated depression and self-reported suicidality.
Methods
Data and study population
We used data from a nationwide cross-sectional survey of Korean transgender adults, in which stressors specific to transgender identity were measured along with health-related and sociodemographic variables. The online survey was conducted from October 7 to October 31, 2020. Participants were recruited through placing informational notices/advertisements at various channels (e.g., a project-specific Facebook page and online outreach targeting Korean transgender communities). All individuals who entered the survey link were screened for eligibility, asked to read an informed consent document, and indicate their agreement to participate in this study. The study procedures were reviewed and approved by the Institutional Review Board of Korea University (KUIRB-2020-0189-01).
Those who (1) were Korean living in Korea, (2) 19 years of age or older, and (3) identified themselves as transgender were eligible to participate in the survey. We used a best-practice two-step method to assess transgender identity by asking participants to report their birth-assigned sex (i.e., male or female) and their current gender identity (i.e., man, woman, or neither man nor woman).24 Based on these variables, participants were then categorized into four groups as follows: trans woman, trans man, nonbinary assigned female at birth (AFAB), and nonbinary assigned male at birth (AMAB). In this study, we used the term transgender to include both binary transgender participants (i.e., trans woman and trans man) and nonbinary participants.
A total of 995 individuals started the online survey. For the present study, we excluded participants who did not provide informed consent (N=164), did not meet the eligibility criteria (N=141), or dropped out of the survey (N=99). Among the 591 transgender adults, we further excluded those who had missing values in GICEs, mental health indicators, and covariates (N=25). In the final analytic sample, a total of 566 transgender adult participants were included.
Measures
Lifetime exposure to GICEs
Participants were asked to answer the following two questions: “have you ever been advised to receive therapy or counseling that aims to make you live according to your sex assigned at birth?” and “have you ever received such therapy or counseling?” Each question was responded to as either “yes” or “no.” Based on participants' responses to these questions, a variable was created to define participants who (1) “never had GICE-related experiences,” (2) “received a referral, but did not undergo GICEs,” or (3) “undergone GICEs.”
We also asked participants who had “undergone GICEs” about the type of practitioner that conducted GICEs. Available options were “psychologist/counselor,” “healthcare provider,” “religious leader,” and “others not listed,” with multiple choices allowed. Based on the Medical Service Act of Korea, psychologists/counselors are not classified as health care providers.
Mental health indicators
We included past-week depressive symptoms, medical diagnosis or treatment of depression and panic disorder, and past 12-month suicidal ideation, suicide attempts, and self-harm in the analysis, all of which were dichotomously coded. Depressive symptoms were assessed using the 20-item Center for Epidemiologic Studies Depression Scale (CES-D),25 which has been validated in the Korean population.26 Participants were asked to answer 20 statements to indicate the frequency of each depressive symptom in the past week on a 4-point Likert scale, ranging from 0 (“less than one day”) to 3 (“five to seven days”). Participants who had a score of at least 16 on the CES-D were considered having depressive symptoms.
Depression and panic disorder were measured using the following single-item questions: “have you been medically diagnosed with or treated for depression in healthcare institutions between January 1 and December 31, 2019?” and “have you been medically diagnosed with or treated for panic disorder in healthcare institutions between January 1 and December 31, 2019?” Participants answered “yes” or “no” to each question.
Suicidal ideation and suicide attempts were each assessed with single yes/no questions. Participants were asked, during the past 12 months, whether they had ever seriously thought about suicide or attempted suicide. In addition, self-harm (including suicidal and nonsuicidal self-injurious behaviors) was measured with the following yes/no question: “have you ever tried to harm yourself within the last 12 months?”
Covariates
The following sociodemographic variables were included in the analysis: transgender identity, sexual orientation, age, residential area, educational attainment, monthly individual income (based on 1,000 Korean Won=0.87 USD), and employment status. In addition, a recruitment channel through which individuals participated was also included in the adjusted model.
Family support of gender identity and transgender identity discrimination were also assessed and included as covariates based on previous studies.7,8 Participants were asked to respond whether family members were supportive of their gender identity at the time of data collection. Family support of gender identity was coded as follows: unsupportive, neutral, supportive, or do not know. Transgender identity discrimination was assessed by asking the following yes/no question: “During the past 12 months, have you experienced discrimination based on your transgender identity or gender expression?”
Statistical analyses
Bivariate analyses were conducted using Chi-square tests to compare the prevalence of lifetime exposure to GICEs across covariates, including sociodemographic variables. Multivariable analyses were performed to investigate the associations between lifetime exposure to GICEs and mental health indicators. All covariates listed above were included in the adjusted model.
We used a log-linked Poisson regression model with a robust sandwich variance estimator since the prevalence of mental health indicators was similar to or higher than 20.0%.27 Results are reported as prevalence ratios with the corresponding 95% confidence intervals (CIs). Due to the small amount of missing data for all variables included in the analysis (0.04%), we did not use any methods for addressing missing data. All analyses were conducted using STATA/MP version 16.0 (StataCorp, LLC, College Station, TX).
Results
Table 1 presents the prevalence of lifetime exposure to GICEs by transgender identity. Of the 566 participants, 182 (32.2%) identified as trans women; 106 (18.7%) as trans men; 215 (38.0%) as nonbinary AFAB; and 63 (11.1%) as nonbinary AMAB. Among the total participants, 69 (12.2%) had “received a referral, but did not undergo GICEs,” and 65 (11.5%) had “undergone GICEs.”
Table 1.
Prevalence of Lifetime Exposure to Gender Identity Change Efforts by Transgender Identity Among Korean Transgender Adults (N=566)
|
Full sample
|
Trans woman
|
Trans man
|
Nonbinary AFAB
|
Nonbinary AMAB
|
|
|---|---|---|---|---|---|
| N (%) | N (%) | N (%) | N (%) | N (%) | |
| Total | 566 (100.0) | 182 (32.2) | 106 (18.7) | 215 (38.0) | 63 (11.1) |
| Lifetime exposure to GICEs | |||||
| Never had GICE-related experiences | 432 (76.3) | 118 (64.8) | 76 (71.7) | 184 (85.6) | 54 (85.7) |
| Received a referral, but did not undergo GICEs | 69 (12.2) | 31 (17.0) | 13 (12.3) | 19 (8.8) | 6 (9.5) |
| Undergone GICEs | 65 (11.5) | 33 (18.1) | 17 (16.0) | 12 (5.6) | 3 (4.8) |
| Practitioner of GICEsa (N=65) | |||||
| Psychologist/counselor | 42 (64.6) | 20 (60.6) | 11 (64.7) | 8 (66.7) | 3 (100.0) |
| Health care provider | 36 (55.4) | 20 (60.6) | 8 (47.1) | 7 (58.3) | 1 (33.3) |
| Religious leader | 12 (18.5) | 6 (18.2) | 3 (17.6) | 3 (25.0) | 0 (0.0) |
| Others not listed | 3 (4.6) | 2 (6.0) | 0 (0.0) | 1 (8.3) | 0 (0.0) |
Multiple choices are allowed.
AFAB, assigned female at birth; AMAB, assigned male at birth; GICEs, gender identity change efforts.
Specifically, trans women and trans men were more likely than nonbinary participants to report GICE experiences (both “received a referral, but did not undergo GICEs” and “undergone GICEs”). Of the 65 participants who had “undergone GICEs” in their lifetime, the majority reported that a person who provided GICEs to them was a psychologist/counselor (64.6%), followed by a health care provider (55.4%) and a religious leader (18.5%).
The majority of participants whose age ranged from 19 to 60 (mean age=25.5; standard deviation=5.8) were young adults in the current study. As shown in Table 2, more than half did not identify as heterosexual, lived in a metropolitan area, graduated high school or less, and reported their monthly income as none. Table 2 also shows that the prevalence of lifetime exposure to GICEs significantly varied by several covariates, including age and family support of gender identity. Specifically, those who were older or whose family members were unsupportive of their gender identity were more likely to report having “undergone GICEs,” compared with their respective counterparts.
Table 2.
Distribution of the Study Participants and Prevalence of Lifetime Exposure to Gender Identity Change Efforts Among Korean Transgender Adults (N=566)
|
Full sample (N=566)
|
Lifetime exposure to GICEs
|
||||
|---|---|---|---|---|---|
|
Never had GICE-related experiences (N=432)
|
Received a referral, but did not undergo GICEs (N=69)
|
Undergone GICEs (N=65)
|
p a | ||
| N (%) | N (%) | N (%) | N (%) | ||
| Sexual orientation | 0.240 | ||||
| Heterosexual | 104 (18.4) | 69 (66.4) | 17 (16.4) | 18 (17.3) | |
| Lesbian/gay | 62 (11.0) | 46 (74.2) | 9 (14.5) | 7 (11.3) | |
| Bisexual | 233 (41.2) | 179 (76.8) | 29 (12.5) | 25 (10.7) | |
| Asexual | 133 (23.5) | 109 (82.0) | 12 (9.0) | 12 (9.0) | |
| Others | 34 (6.0) | 29 (85.3) | 2 (5.9) | 3 (8.8) | |
| Age (years; range=19–60) | 0.026 | ||||
| 19–24 | 313 (55.3) | 250 (79.9) | 33 (10.5) | 30 (9.6) | |
| 25–29 | 143 (25.3) | 106 (74.1) | 25 (17.5) | 12 (8.4) | |
| 30–34 | 62 (11.0) | 43 (69.4) | 5 (8.1) | 14 (22.6) | |
| 35–39 | 34 (6.0) | 24 (70.6) | 4 (11.8) | 6 (17.7) | |
| 40–60 | 14 (2.5) | 9 (64.3) | 2 (14.3) | 3 (21.4) | |
| Residential area | 0.624 | ||||
| Metropolitan area | 404 (71.4) | 304 (75.3) | 52 (12.9) | 48 (11.9) | |
| Nonmetropolitan area | 162 (28.6) | 128 (79.0) | 17 (10.5) | 17 (10.5) | |
| Educational attainment | 0.467 | ||||
| High school graduate or less | 348 (61.5) | 272 (78.2) | 41 (11.8) | 35 (10.1) | |
| 2-Year college graduate | 42 (7.4) | 30 (71.4) | 8 (19.1) | 4 (9.5) | |
| 4-Year college graduate | 155 (27.4) | 113 (72.9) | 19 (12.3) | 23 (14.8) | |
| Graduate school graduate | 21 (3.7) | 17 (81.0) | 1 (4.8) | 3 (14.3) | |
| Monthly individual income (103 Korean Won) | 0.738 | ||||
| None | 313 (55.3) | 245 (78.3) | 38 (12.1) | 30 (9.6) | |
| <1,000 | 74 (13.1) | 58 (78.4) | 7 (9.5) | 9 (12.2) | |
| 1,000–1,999 | 93 (16.4) | 68 (73.1) | 13 (14.0) | 12 (12.9) | |
| 2,000–2,999 | 57 (10.1) | 42 (73.7) | 6 (10.5) | 9 (15.8) | |
| ≥3,000 | 29 (5.1) | 19 (65.5) | 5 (17.2) | 5 (17.2) | |
| Employment status | 0.018 | ||||
| Student | 222 (39.2) | 178 (80.2) | 21 (9.5) | 23 (10.4) | |
| Permanent employment | 104 (18.4) | 80 (76.9) | 11 (10.6) | 13 (12.5) | |
| Nonpermanent employment | 47 (8.3) | 40 (85.1) | 6 (12.8) | 1 (2.1) | |
| Self-employed | 60 (10.6) | 36 (60.0) | 10 (16.7) | 14 (23.3) | |
| Unemployed | 133 (23.5) | 98 (73.7) | 21 (15.8) | 14 (10.5) | |
| Recruitment channel | 0.200 | ||||
| Facebook page or online transgender communities | 148 (26.2) | 110 (74.3) | 18 (12.2) | 20 (13.5) | |
| Primary health care clinics | 68 (12.0) | 48 (70.6) | 10 (14.7) | 10 (14.7) | |
| Community-based LGBT organizations | 92 (16.3) | 82 (89.1) | 6 (6.5) | 4 (4.4) | |
| Acquaintance or friends | 196 (34.6) | 145 (74.0) | 27 (13.8) | 24 (12.2) | |
| Others not listed | 62 (11.0) | 47 (75.8) | 8 (12.9) | 7 (11.3) | |
| Family support of gender identity | <0.001 | ||||
| Unsupportive | 144 (25.4) | 87 (60.4) | 30 (20.8) | 27 (18.8) | |
| Neutral | 94 (16.6) | 71 (75.5) | 12 (12.8) | 11 (11.7) | |
| Supportive | 135 (23.9) | 104 (77.0) | 12 (8.9) | 19 (14.1) | |
| Do not know | 193 (34.1) | 170 (88.1) | 15 (7.8) | 8 (4.2) | |
| Transgender identity discrimination | 0.126 | ||||
| Not experienced | 193 (34.1) | 155 (80.3) | 23 (11.9) | 15 (7.8) | |
| Experienced | 373 (65.9) | 277 (74.3) | 46 (12.3) | 50 (13.4) | |
p-Value of the Chi-square test comparing the prevalence of lifetime exposure to GICEs by covariates.
The prevalence of mental health indicators is presented in Table 3, stratified by transgender identity. A total of 70.1% of participants reported having depressive symptoms during the past week. The prevalence of ever being diagnosed with or treated for depression and panic disorder in the previous year were 57.1% and 24.6%, respectively. The prevalence of suicidal ideation and suicide attempts were 62.9% and 19.4%, respectively. In addition, the prevalence of past 12-month self-harm was 37.3%. When stratified by transgender identity, the prevalence of all mental health indicators was the lowest among trans men, except for suicide attempts whereby trans men and nonbinary AMAB participants have lower prevalence compared with trans women and nonbinary AFAB.
Table 3.
Prevalence of Mental Health Indicators by Transgender Identity Among Korean Transgender Adults (N=566)
| Mental health indicators |
Full sample (N=566)
|
Trans woman (N=182)
|
Trans man (N=106)
|
Nonbinary AFAB (N=215)
|
Nonbinary AMAB (N=63)
|
|---|---|---|---|---|---|
| N (%) | N (%) | N (%) | N (%) | N (%) | |
| Past-week depressive symptoms | 397 (70.1) | 135 (74.2) | 60 (56.6) | 153 (71.2) | 49 (77.8) |
| Medically diagnosed or treated depression | 323 (57.1) | 100 (55.0) | 43 (40.6) | 135 (62.8) | 45 (71.4) |
| Medically diagnosed or treated panic disorder | 139 (24.6) | 41 (22.5) | 18 (17.0) | 63 (29.3) | 17 (27.0) |
| Past 12-month suicidal ideation | 356 (62.9) | 115 (63.2) | 54 (50.9) | 144 (67.0) | 43 (68.3) |
| Past 12-month suicide attempts | 110 (19.4) | 42 (23.1) | 14 (13.2) | 46 (21.4) | 8 (12.7) |
| Past 12-month self-harm | 211 (37.3) | 58 (31.9) | 32 (30.2) | 99 (46.1) | 22 (34.9) |
Table 4 shows the associations between lifetime exposure to GICEs and mental health indicators. Among the participants who had “undergone GICEs,” statistically significant associations were observed with depression, panic disorder, and suicide attempts, but not with depressive symptoms, suicidal ideation, and self-harm. Specifically, those who had undergone GICEs had a 1.34-times (95% CI=1.11–1.61) and 2.52-times (95% CI=1.75–3.64) higher prevalence of being diagnosed with or treated for depression and panic disorder during the previous year, respectively. In addition, those who had “undergone GICEs” had a 1.73-times (95% CI=1.10–2.72) higher prevalence of past 12-month suicide attempts than those who had “never had GICE-related experiences.”
Table 4.
Associations Between Lifetime Exposure to Gender Identity Change Efforts and Mental Health Indicators Among Korean Transgender Adults (N=566)
|
Distribution
|
Prevalence
|
Unadjusted
|
Adjusted
a
|
|||
|---|---|---|---|---|---|---|
| N (%) | N (%) | PR | 95% CI | PR | 95% CI | |
| Past-week depressive symptoms | ||||||
| Never had GICE-related experiences | 432 (76.3) | 298 (69.0) | 1 | Reference | 1 | Reference |
| Received a referral, but did not undergo GICEs | 69 (12.2) | 51 (73.9) | 1.07 | 0.92–1.25 | 1.08 | 0.93–1.26 |
| Undergone GICEs | 65 (11.5) | 48 (73.9) | 1.07 | 0.91–1.25 | 1.13 | 0.97–1.32 |
| Medically diagnosed or treated depression | ||||||
| Never had GICE-related experiences | 432 (76.3) | 241 (55.8) | 1 | Reference | 1 | Reference |
| Received a referral, but did not undergo GICEs | 69 (12.2) | 37 (53.6) | 0.96 | 0.76–1.22 | 1.01 | 0.80–1.27 |
| Undergone GICEs | 65 (11.5) | 45 (69.2) | 1.24b | 1.03–1.49 | 1.34c | 1.11–1.61 |
| Medically diagnosed or treated panic disorder | ||||||
| Never had GICE-related experiences | 432 (76.3) | 94 (21.8) | 1 | Reference | 1 | Reference |
| Received a referral, but did not undergo GICEs | 69 (12.2) | 15 (21.7) | 1.00 | 0.62–1.62 | 1.13 | 0.69–1.85 |
| Undergone GICEs | 65 (11.5) | 30 (46.2) | 2.12d | 1.54–2.92 | 2.52d | 1.75–3.64 |
| Past 12-month suicidal ideation | ||||||
| Never had GICE-related experiences | 432 (76.3) | 264 (61.1) | 1 | Reference | 1 | Reference |
| Received a referral, but did not undergo GICEs | 69 (12.2) | 49 (71.0) | 1.16 | 0.98–1.38 | 1.16 | 0.98–1.39 |
| Undergone GICEs | 65 (11.5) | 43 (66.2) | 1.08 | 0.90–1.31 | 1.11 | 0.92–1.34 |
| Past 12-month suicide attempts | ||||||
| Never had GICE-related experiences | 432 (76.3) | 73 (16.9) | 1 | Reference | 1 | Reference |
| Received a referral, but did not undergo GICEs | 69 (12.2) | 17 (24.6) | 1.46 | 0.92–2.32 | 1.35 | 0.85–2.15 |
| Undergone GICEs | 65 (11.5) | 20 (30.8) | 1.82c | 1.20–2.77 | 1.73b | 1.10–2.72 |
| Past 12-month self-harm | ||||||
| Never had GICE-related experiences | 432 (76.3) | 159 (36.8) | 1 | Reference | 1 | Reference |
| Received a referral, but did not undergo GICEs | 69 (12.2) | 27 (39.1) | 1.06 | 0.77–1.46 | 1.10 | 0.80–1.51 |
| Undergone GICEs | 65 (11.5) | 25 (38.5) | 1.04 | 0.75–1.46 | 1.19 | 0.85–1.67 |
Adjusted for transgender identity, sexual orientation, age, residential area, educational attainment, monthly individual income, employment status, recruitment channel, family support of gender identity, and transgender identity discrimination.
p<0.05.
p<0.01.
p<0.001.
CI, confidence interval; PR, prevalence ratio.
However, there were no significant associations between having “received a referral, but did not undergo GICEs” and all mental health indicators. For example, those who had received a referral, but did not undergo GICEs did not show significantly higher prevalence of past-week depressive symptoms (aPR = 1.08, 95% CI = 0.93−1.26).
Discussion
Using the largest survey of transgender adults in Korea to date, our findings show that a considerable proportion of transgender participants were exposed to GICEs during their lifetime. Of the total 566 participants, 11.5% had received GICEs in a professional practice, many of whom reported their practitioner being a psychologist/counselor or a health care provider. In addition, 12.2% of the sample had been advised to receive GICEs but did not undergo this process.
Notably, lifetime exposure to GICEs among transgender adults was higher in prevalence when compared with previous research reporting on lifetime SOCEs among cisgender (i.e., nontransgender) lesbian, gay, and bisexual (LGB) adults in Korea. According to a recent study in Korea, 2.5% of cisgender LGB participants had undergone SOCEs and 9.3% had been referred to but did not undergo SOCEs.28 The prevalence of Korean transgender adults who had undergone GICEs was much higher than the prevalence of Korean cisgender LGB adults who had undergone SOCEs, suggesting a more aggressive attempt to erase transgender people's identity.
The current study is the first to examine the associations between lifetime exposure to GICEs and mental health among Korean transgender adults. We found that participants who had undergone GICEs during their lifetime were more likely to report medically diagnosed or treated depression and panic disorder as well as suicide attempts, compared with those who had not experienced the practices. Our findings corroborate previous studies conducted outside of Korea showing significant associations between lifetime exposure to GICEs and adverse mental health outcomes among transgender individuals.7,8 Specifically, a previous study demonstrated that participants who were exposed to GICEs were 1.56-times more likely to have severe psychological distress than those without such exposure.8
However, the associations of having undergone GICEs were not significant with past-week depressive symptoms as well as past 12-month suicidal ideation and self-harm. These insignificant results may be attributable to the difference in severity between mental health indicators. Medically diagnosed or treated depression and suicide attempts could be considered as more severe indicators of mental health, compared with depressive symptoms and suicidal ideation, respectively. We also found that the baseline prevalence of past-week depressive symptoms, suicidal ideation, and self-harm was high. A low variability between those who had not had GICE-related experiences (the reference group) and those who had undergone GICEs may also have led to insignificant findings.
Findings from the current study support the GMSR model, which posits that gender-related stressors may lead to poor physical and mental health among transgender individuals.14 As an extreme type of gender-related stress, GICEs may contribute to mental health disparities documented among Korean transgender adults.21 Notably, we found that the associations between having undergone GICEs and mental health indicators (e.g., suicide attempts) remained significant even after adjusting for transgender identity discrimination in general, which itself is a strong predictor of adverse mental health outcomes (Supplementary Tables S1 and S2).
These findings should be understood within the context of the Korean society, in which transgender individuals experience substantial barriers to social acceptance and thus experience several unique and chronic gender-related stressors. According to a recent report from the National Human Rights Commission of Korea, 44.0% of the 373 transgender participants whose family members knew of their gender identity reported being prevented from expressing themselves through dress and makeup.18 Furthermore, Korea has strict requirements for legal gender change and barriers to gender-affirming health care,16,29 both of which are forms of institutionalized transphobia. For example, current policy in Korea requires transgender individuals to undergo sterilization to legally change their gender.29
Cumulative exposure to the aforementioned and other gender-related stressors contribute to internalized transphobia, which manifests in transgender individuals holding negative views of themselves and the transgender community broadly.14 In further evidence of the pernicious impact of internalized transphobia, a previous study in Korea found that internalized transphobia had significant relationships with both depressive symptoms and suicidality.30 Given that, there is an urgent need to provide trauma-informed care for those who had experienced GICEs and develop gender-affirmative training for mental health professionals to provide ethical and gender-competent treatment to members of this community in Korea.
Limitations and strengths
Findings from this study should be interpreted with caution due to the following limitations. First, our cross-sectional study design does not allow conclusions about causal relationships between GICE experiences and mental health indicators. Second, it is difficult to generalize our findings to the total population of transgender individuals due to the nonprobability sampling method. Third, transgender identity was assessed using the two-step method and classified into four categories, which may not reflect the wide range of participants' gender identities.
Other limitations are related to the assessment of GICEs. We developed specific measures to assess lifetime exposure to GICEs for the current study, as there are no known validated measures of this construct in Korea. In addition, we did not ask participants who had undergone GICEs about details of the experience, including specific modalities, promoters of GICEs, and did not inquire about participants' age at their first exposure to GICEs. Regarding the practitioner of GICEs, the distinction between psychologists/counselors and health care providers is likely to be ambiguous to the general public, despite the distinction between these two professional labels based on the Medical Service Act of Korea. Thus, we cannot exclude the possibility of overlap between these two professional labels in our study.
Despite these limitations, our study also had several strengths. We used data from the largest cross-sectional survey of transgender adults ever conducted in Korea. We also provided an understanding of GICEs and their impact on transgender adults' mental health for the first time in Korea. Third, we assessed transgender participants' mental health with various indicators, including depression and panic disorder based on the medical diagnosis or treatment history.
Conclusions
Our findings suggested that a sizable portion of Korean transgender adults have been exposed to GICEs in their lifetime. In the first study ever to investigate the association between GICEs and mental health outcomes in Korea, we found that participants with lifetime exposure to GICEs are more likely to get diagnosed with or treated for depression and panic disorder as well as have experienced past 12-month suicide attempts. Findings from this study highlight a need for effective gender-affirmative counseling or therapies to address the mental health vulnerabilities of transgender people in Korea, particularly those who have been exposed to GICEs. Finally, legal sanctions should be introduced to ban GICEs in Korea and thus ultimately improve the mental health of Korean transgender populations.
Supplementary Material
Acknowledgments
The authors would like to acknowledge activists of community-based LGBT organizations and health care providers of primary health care clinics for their support and assistance in data collection as well as volunteer consultants for their support and assistance in the development of survey questionnaires. The authors also appreciate transgender adults who participated in our study.
Abbreviations Used
- AFAB
assigned female at birth
- AMAB
assigned male at birth
- aPR
adjusted prevalence ratio
- CES-D
Center for Epidemiologic Studies Depression Scale
- CI
confidence interval
- GICEs
gender identity change efforts
- GMSR
gender minority stress and resilience
- LGB
lesbian, gay, and bisexual
- PR
prevalence ratio
- SOCEs
sexual orientation change efforts
- SOGICEs
sexual orientation and gender identity change efforts
Authors' Contributions
H.L. and S.-S.K. conceptualized the study. H.L., S.C., R.K., Y.-J.E., H.Y., and S.-S.K. implemented data collection. H.L. conducted data analysis, interpreted findings, and drafted the article. D.O., A.J.R., S.C., R.K., Y.-J.E., H.Y., and S.-S.K. interpreted findings and revised the work critically for important intellectual content. All coauthors reviewed and approved the final version of the article before submission and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Author Disclosure Statement
No competing financial interests exist.
Funding Information
This study was partially supported by the National Human Rights Commission of the Republic of Korea. The first author (H.L.) was supported by the Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education (NRF-2020R1A6A3A13060799). The third author (A.J.R.) was supported by the National Institute of Allergy and Infectious Diseases (T32AI102623). The funding organizations had no role in study design; in the collection, analysis, and interpretation of data; in the writing of the report; and in the decision to submit the article for publication.
Supplementary Material
Cite this article as: Lee H, Operario D, Restar AJ, Choo S, Kim R, Eom Y-J, Yi H, Kim S-S (2023) Gender identity change efforts are associated with depression, panic disorder, and suicide attempts in South Korean transgender adults, Transgender Health 8:3, 273–281, DOI: 10.1089/trgh.2021.0171.
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