Abstract
Objectives. To examine inequities in conversion practice exposure across intersections of ethnoracial groups and gender identity in the United States.
Methods. Data were obtained from The Population Research in Identity and Disparities for Equality Study of sexual and gender minority people from 2019 to 2021 (n = 9274). We considered 3 outcomes: lifetime exposure, age of first exposure, and period between first and last exposure among those exposed to conversion practices. We used log-binomial, Cox proportional hazards, and negative binomial models to examine inequities by ethnoracial groups and gender identity adjusting for confounders. We considered additive interaction.
Results. Conversion practice prevalence was highest among minoritized ethnoracial transgender and nonbinary participants (TNB; 8.6%). Compared with White cisgender participants, minoritized ethnoracial TNB participants had twice the prevalence (prevalence ratio = 2.16; 95% confidence interval [CI] = 1.62, 2.86) and risk (hazard ratio = 2.04; 95% CI = 1.51, 2.69) of conversion practice exposure. Furthermore, there was evidence of a positive additive interaction for age of first exposure.
Conclusions. Minoritized ethnoracial TNB participants were most likely to recall experiencing conversion practices.
Public Health Implications. Policies banning conversion practices may reduce the disproportionate burden experienced by minoritized ethnoracial TNB participants. (Am J Public Health. 2024;114(4):424–434. https://doi.org/10.2105/AJPH.2024.307580)
Conversion practices, also known as part of a broader set of efforts to change sexual orientation and gender identity, refer to organized attempts that seek to suppress or redirect noncisgender gender identity and expression and nonheterosexual sexual attraction.1,2 These harmful practices—which include religious rituals, speech-based therapy, physical deprivation, aversion therapy, electroconvulsive therapy, and medication-induced emetic responses3—are often aimed at sexual and gender minority (SGM) individuals and have been associated with negative mental health outcomes such as distress, depression, and suicidal ideation and attempt.4–8 While several professional bodies have denounced conversion practices given the evidence of harm,9 only 22 states and the District of Columbia currently have laws banning conversion practices for minors, and 3 have federal injunctions preventing bans as of October 2023.10
Studies suggest that approximately 13% of SGM individuals in the United States have overall experienced conversion practices4,5,8,11,12 with higher prevalence reported among transgender and nonbinary (TNB) people (4% to 31%) compared to cisgender people (2% to 21%).5,6,13 Conceptually, conversion practices can be viewed as a manifestation of multiple forms of discrimination—including homophobia, systemic racism, and cissexism—used to uphold cisheteronormativity and White supremacy, socio-structural systems wherein cisgender heterosexual identities and Whiteness are normalized and privileged; this erases and marginalizes SGM individuals and minoritized ethnoracial groups.1,14–16 However, previous research on conversion practices and their negative outcomes has only considered a single axis of identity, such as gender (e.g., cisgender or TNB people),4–6 sexual orientation (e.g., sexual minority men),8,17 or minoritized ethnoracial identity (e.g., Black, Indigenous, Asian, Pacific Islander, Hispanic, or Latina/e/o/x).4–6 This approach obscures how interlocking systems of oppression and discrimination impact conversion practice exposure for SGM people who live their lives at the intersection of multiple minoritized identities.18 Therefore, we applied intersectionality19–21 to inform our research question, study design, and interpretation. We posit that the inequities to conversion practice exposure, timing, and duration experienced by TNB people from minoritized ethnoracial backgrounds will be greater than the reference intersection.
Intersectionality, a Black feminist theoretical framework rooted in social justice movements of the early 19th century and codified in a legal context in the 1980s and 1990s, posits that the experiences of individuals with multiple marginalized identities are differentially shaped by socio-structural systems that interact to provide unearned privilege for some while oppressing others of different social positions.19–21 In this study, we were interested in 2 such systems, systemic racism and cissexism, that are proxied by self-reported ethnoracial and gender identity in The Population Research in Identity and Disparities for Equality (PRIDE) Study. By accounting for the impact of multiple forms of systemic oppression in this study,14 we sought to better understand the inequities faced by SGM individuals with multiply marginalized identities, particularly TNB individuals from minoritized ethnoracial backgrounds.
METHODS
We used data from 3 waves of The PRIDE Study, a longitudinal cohort of SGM adults recruited from 2019 to 2021 in the United States. Previous work has described the methods of (prospective) participant engagement, enrollment, retention, and data acquisition as well as the novel Web-based platform that The PRIDE Study uses.22,23 The eligibility criteria for The PRIDE Study included being aged 18 years or older, being a resident of the United States or its territories, identifying as a gender or sexual minority person, and being comfortable with reading in English. Eligible participants provided electronic informed consent through an online participant portal. Upon enrollment, participants were invited to complete the lifetime and current annual health and experiences questionnaire, with future invitations to complete any subsequent annual questionnaires. Our analysis was restricted to participants who completed the lifetime and at least 1 annual questionnaire during the study period.
Ethnoracial Identity
The PRIDE Study participants were able to self-identify their ethnoracial identity by selecting any (or multiple) of the following options: American Indian or Alaska Native; Asian; Black, African American, or African; Hispanic, Latino, or Spanish; Middle Eastern or North African; Native Hawaiian or other Pacific Islander; White; and None of these fully describe me (with a free response option). For participants who completed the free response option, we recoded them as White if they did not endorse any other ethnoracial identity and self-identified as White or of Western European descent (e.g., Irish). Because of the limited sample size within some ethnoracial groups, we collapsed ethnoracial identities into a binary variable that included White and minoritized ethnoracial groups. We use the term “minoritized ethnoracial” to highlight the context in which individuals are made to be minorities in institutions that are structured to uphold White supremacy.14,16 Therefore, minoritized ethnoracial individuals in this analysis include participants in these ethnoracial groups: American Indian or Alaska Native; Asian; Black, African American, or African; Hispanic, Latino, or Spanish; Middle Eastern or North African; or Native Hawaiian or Pacific Islander, as they are all harmed by systemic racism in the United States.
Gender Identity and Sex Assigned at Birth
Participants were asked to report their current gender identity with the option to select multiple responses (agender, cisgender man, cisgender woman, genderqueer, man, nonbinary, questioning, transgender man, transgender woman, Two-Spirit, woman, and another gender identity) and sex assigned at birth (female or male). To align with an Indigenous conceptualization of Two-Spirit,24 participants who exclusively self-identified as White were not included as Two-Spirit for current gender identity in the analysis. However, it is possible that these participants may still originate from Indigenous communities; thus, we presented our results that included all participants that self-identified as Two-Spirit in Appendix Tables A and B (available as supplements to the online version of this article at https://ajph.org).
We then used a 2-step procedure for coding items on gender identity and sex assigned at birth.25,26 Cisgender participants were those whose gender identity was concordant with the gender commonly associated with their sex assigned at birth, or if sex assigned at birth was missing, reported their current gender identity as cisgender man or cisgender woman. TNB participants included those whose gender identity was not concordant with the gender commonly associated with their sex assigned at birth or who endorsed any of the following for their current gender identities: agender, genderqueer, nonbinary, questioning, transgender man, transgender woman, Two-Spirit, and another gender identity.
Outcomes
We assessed lifetime exposure to conversion practices with 2 separate questions: “Have you EVER been in therapy or been part of a program or group intended to change your gender or gender identity to be consistent with the sex assigned to you at birth?” and “Have you EVER been in therapy or been part of a program or group intended to change your sexual orientation to heterosexual/straight?” Participants who answered “yes” to either question received 2 follow-up questions assessing the age of first and last exposure. For this analysis, we created a singular indicator (yes/no) for any lifetime exposure to conversion practices. To assess the age of first exposure, we used the youngest age reported by participants who experienced gender or sexual orientation conversion practice. Lastly, years between first and last exposure were quantified by calculating the difference between the latest age of last exposure and the earliest age of first exposure for gender or sexual orientation conversion practices.
Covariates
Given that our analysis draws from intersectionality as a conceptual framework, which situates individuals within overlapping socio-structural systems that afford privilege to some people while oppressing others, we considered only the following covariates as potential confounders in our analysis: age (continuous), annual survey completion year (2019, 2020, and 2021), US Census division of residence (East North Central, East South Central, Mid-Atlantic, Mountain, New England, Pacific, South Atlantic, West North Central, West South Central, and unknown), and religious upbringing (yes/no). We did not adjust for socioeconomic position (i.e., education level and individual annual income) because these measures are potentially mediators or descendants of recall history of conversion practices. However, education level and annual income, along with ethnoracial groups, gender identity, and sexual orientation, are included in Table 1 for the purpose of describing the sample. Similar to current gender, participants who exclusively self-reported White were excluded as Two-Spirit for sexual orientation.
TABLE 1—
Participant Sociodemographic Characteristics, Religious Upbringing, and Experiences With Conversion Practices: United States, 2019 to 2021
| Total (n = 9274), No. (%), or Mean, Median ± SD | Minoritized Ethnoracial Transgender and Nonbinary (n = 888), No. (%) or Mean, Median ± SD | Minoritized Ethnoracial Cisgender (n = 970), No. (%) or Mean, Median ± SD | White Transgender and Nonbinary (n = 3280), No. (%) or Mean, Median ± SD | White Cisgender (n = 4136), No. (%) or Mean, Median ± SD | |
| Age | 35.5, 31.0 ± 14.1 | 29.9, 26.3 ± 11.4 | 35.8, 31.2 ± 13.8 | 32.1, 28.6 ± 12.0 | 39.4, 35.0 ± 15.2 |
| Ethnoracial identitya | |||||
| American Indian or Alaska Native | 312 (3.4) | 184 (20.7) | 128 (13.2) | 0 (0.0) | 0 (0.0) |
| Asian | 484 (5.2) | 228 (25.7) | 256 (26.4) | 0 (0.0) | 0 (0.0) |
| Black, African American, or African | 400 (4.3) | 178 (20.0) | 222 (22.9) | 0 (0.0) | 0 (0.0) |
| Hispanic, Latino, or Spanish | 689 (7.4) | 312 (35.1) | 377 (38.9) | 0 (0.0) | 0 (0.0) |
| Middle Eastern or North African | 137 (1.5) | 78 (8.8) | 59 (6.1) | 0 (0.0) | 0 (0.0) |
| Native Hawaiian or Pacific Islander | 27 (0.3) | 14 (1.6) | 13 (1.3) | 0 (0.0) | 0 (0.0) |
| White | 8333 (89.9) | 498 (56.1) | 427 (44.0) | 3274 (99.8) | 4134 (100.0) |
| Another ethnoracial identity | 134 (1.4) | 47 (5.3) | 31 (3.2) | 37 (1.1) | 19 (0.5) |
| Gender identitya | |||||
| Agender | 455 (4.9) | 95 (10.7) | 0 (0.0) | 360 (11.0) | 0 (0.0) |
| Cisgender man | 1217 (13.1) | 17 (1.9) | 255 (26.3) | 48 (1.5) | 897 (21.7) |
| Cisgender woman | 2271 (24.5) | 40 (4.5) | 384 (39.6) | 168 (5.1) | 1679 (40.6) |
| Genderqueer | 1259 (13.6) | 228 (25.7) | 0 (0.0) | 1031 (31.4) | 0 (0.0) |
| Man | 2037 (22.0) | 139 (15.7) | 267 (27.5) | 453 (13.8) | 1178 (28.5) |
| Nonbinary | 2054 (22.1) | 462 (52.0) | 0 (0.0) | 1592 (48.5) | 0 (0.0) |
| Questioning | 442 (4.8) | 111 (12.5) | 0 (0.0) | 331 (10.1) | 0 (0.0) |
| Transgender man | 1183 (12.8) | 237 (26.7) | 0 (0.0) | 946 (28.8) | 0 (0.0) |
| Transgender woman | 523 (5.6) | 96 (10.8) | 0 (0.0) | 427 (13.0) | 0 (0.0) |
| Two-Spirit | 49 (0.5) | 49 (5.5) | 0 (0.0) | 0 (0.0) | 0 (0.0) |
| Woman | 2231 (24.1) | 148 (16.7) | 271 (27.9) | 559 (17.0) | 1253 (30.3) |
| Another gender identity | 556 (6.0) | 142 (16.0) | 0 (0.0) | 414 (12.6) | 0 (0.0) |
| Sexual orientationa | |||||
| Asexual | 955 (10.3) | 151 (17.0) | 59 (6.1) | 547 (16.7) | 198 (4.8) |
| Bisexual | 2826 (30.5) | 304 (34.2) | 294 (30.3) | 1127 (34.4) | 1101 (26.6) |
| Gay | 2985 (32.2) | 162 (18.2) | 419 (43.2) | 552 (16.8) | 1852 (44.8) |
| Lesbian | 2139 (23.1) | 146 (16.4) | 215 (22.2) | 618 (18.8) | 1160 (28.0) |
| Pansexual | 1514 (16.3) | 220 (24.8) | 101 (10.4) | 770 (23.5) | 423 (10.2) |
| Queer | 3682 (39.7) | 452 (50.9) | 248 (25.6) | 1821 (55.5) | 1161 (28.1) |
| Questioning | 273 (2.9) | 55 (6.2) | 14 (1.4) | 148 (4.5) | 56 (1.4) |
| Same-gender loving | 479 (5.2) | 75 (8.4) | 53 (5.5) | 193 (5.9) | 158 (3.8) |
| Straight/heterosexual | 176 (1.9) | 42 (4.7) | 2 (0.2) | 114 (3.5) | 18 (0.4) |
| Two-Spirit | 24 (0.3) | 23 (2.6) | 1 (0.1) | 0 (0.0) | 0 (0.0) |
| Another sexual orientation | 354 (3.8) | 56 (6.3) | 20 (2.1) | 204 (6.2) | 74 (1.8) |
| Education level | |||||
| High school or less | 509 (5.5) | 84 (9.5) | 37 (3.8) | 241 (7.3) | 147 (3.6) |
| Some college | 2089 (22.5) | 278 (31.3) | 190 (19.6) | 926 (28.2) | 695 (16.8) |
| 4-y college graduate | 2850 (30.7) | 269 (30.3) | 290 (29.9) | 1040 (31.7) | 1251 (30.2) |
| Advanced degree | 2958 (31.9) | 150 (16.9) | 353 (36.4) | 793 (24.2) | 1662 (40.2) |
| Missing | 868 (9.4) | 107 (12.0) | 100 (10.3) | 280 (8.5) | 381 (9.2) |
| Individual income, $ | |||||
| 0–20 000 | 3129 (33.7) | 440 (49.5) | 289 (29.8) | 1426 (43.5) | 974 (23.5) |
| 20 001–50 000 | 2411 (26.0) | 209 (23.5) | 247 (25.5) | 853 (26.0) | 1102 (26.6) |
| 50 001–100 000 | 1871 (20.2) | 99 (11.1) | 216 (22.3) | 511 (15.6) | 1045 (25.3) |
| > 100 000 | 950 (10.2) | 25 (2.8) | 112 (11.5) | 199 (6.1) | 614 (14.8) |
| Missing | 913 (9.8) | 115 (13.0) | 106 (10.9) | 291 (8.9) | 401 (9.7) |
| Survey year | |||||
| 2019 | 5341 (57.6) | 419 (47.2) | 530 (54.6) | 1801 (54.9) | 2591 (62.6) |
| 2020 | 2553 (27.5) | 327 (36.8) | 298 (30.7) | 939 (28.6) | 989 (23.9) |
| 2021 | 1380 (14.9) | 142 (16.0) | 142 (14.6) | 540 (16.5) | 556 (13.4) |
| US Census division of residence | |||||
| East North Central | 742 (8.0) | 72 (8.1) | 66 (6.8) | 297 (9.1) | 307 (7.4) |
| East South Central | 1106 (11.9) | 102 (11.5) | 123 (12.7) | 399 (12.2) | 482 (11.7) |
| Mid-Atlantic | 1199 (12.9) | 114 (12.8) | 83 (8.6) | 450 (13.7) | 552 (13.3) |
| Mountain | 642 (6.9) | 37 (4.2) | 35 (3.6) | 258 (7.9) | 312 (7.5) |
| New England | 1460 (15.7) | 125 (14.1) | 156 (16.1) | 478 (14.6) | 701 (16.9) |
| Pacific | 302 (3.3) | 22 (2.5) | 14 (1.4) | 126 (3.8) | 140 (3.4) |
| South Atlantic | 657 (7.1) | 79 (8.9) | 84 (8.7) | 212 (6.5) | 282 (6.8) |
| West North Central | 639 (6.9) | 46 (5.2) | 61 (6.3) | 232 (7.1) | 300 (7.3) |
| West South Central | 2194 (23.7) | 241 (27.1) | 310 (32.0) | 703 (21.4) | 940 (22.7) |
| Missing | 333 (3.6) | 50 (5.6) | 38 (3.9) | 125 (3.8) | 120 (2.9) |
| Religious upbringing | 7169 (77.3) | 678 (76.4) | 759 (78.2) | 2429 (74.1) | 3303 (79.9) |
| Lifetime exposure | 533 (5.7) | 76 (8.6) | 44 (4.5) | 207 (6.3) | 206 (5.0) |
| Age of first exposureb | 18.4, 16.0 ± 8.2 | 16.8, 16.0 ± 8.2 | 18.3, 16.0 ± 6.4 | 18.5, 16.0 ± 10.0 | 18.9, 17.5 ± 6.4 |
| Age of last exposureb | 21.4, 18.0 ± 9.6 | 20.5, 18.0 ± 9.7 | 22.6, 18.0 ± 10.9 | 21.8, 18.0 ± 10.8 | 21.2, 19.0 ± 8.0 |
| Years between first and last exposureb | 3.1, 1.0 ± 6.1 | 3.7, 2.0 ± 6.9 | 4.3, 1.0 ± 8.8 | 3.3, 1.0 ± 6.2 | 2.4, 1.0 ± 4.7 |
Participants may select multiple options; thus, the sum of percentages will be greater than 100%.
Among participants who reported lifetime exposure to conversion practices (n = 533).
Statistical Analysis
Our analysis drew on McCall’s framework for intersectional complexity27 and used a descriptive intercategorical intersectional approach to evaluate the association between the axes of cissexism and systemic racism (as proxied by gender and ethnoracial identities) on measures of conversion practices. We first defined 4 cross-stratified groups based on ethnoracial identity and current gender identity: minoritized ethnoracial cisgender sexual minority individuals, minoritized ethnoracial TNB individuals of any sexual orientation, White cisgender sexual minority individuals, and White TNB individuals of any sexual orientation. We then summarized key sample characteristics and measures of conversion practices using descriptive statistics for the overall sample and by cross-stratified groups. While these categories were selected to encompass groups that are harmed by the interlocking impact of systemic racism and cissexism and are analogous to other intersectional analyses across ethnoracial and gender groups,28 we acknowledge that this approach may obscure meaningful within-group differences and conducted a secondary descriptive analysis that further disaggregated the sample by ethnoracial identities for cisgender and TNB participants.
We used log-binomial models to estimate prevalence ratios (PRs) of lifetime exposure recall, Cox proportional hazards models to estimate hazard ratios (HRs) for age of first exposure, and negative binomial models to estimate count ratios for period from first to last exposure among participants who reported conversion practice exposure. All models adjusted for age, survey year, division of residence, and religious upbringing. For each model, we selected White cisgender participants as the reference group to reflect our theoretical understanding of how White supremacy and cissexism confer certain social advantages that may reduce exposure to conversion practices.
In our survival analysis, we used age (in years) as the time scale. Cohort entry was defined based on participants’ date of birth, while cohort exit was based on the age of the first event (conversion practice) or the age when participants completed their first annual questionnaire (end of observation period). Since the use of age as the time scale adjusts for age, we did not include age as a covariate in the Cox proportional hazard model. Furthermore, the assessment of the proportional hazard assumptions indicated that religious upbringing was not consistent over age (Appendix Table C); therefore, we conducted time-dependent Cox models to account for the dependencies between age and religious upbringing. Specifically, we allowed for the baseline hazard function to differ between 2 age groups (< 24 and ≥ 24 years); this was defined based on an exploratory assessment of Schoenfeld residuals (Appendix Figure A). Additional information regarding model specification is presented in the “Model Specifications” section of the Appendix.
We evaluated additive interaction for each outcome by using the estimated coefficients to calculate the relative excess risk due to interaction (RERI) that tested whether minoritized ethnoracial TNB experienced a disproportionate increase in risk of conversion practices (i.e., “excess risk”).29 RERI values range from negative to positive infinity, and estimates greater than 0 indicate the presence of a positive additive interaction. We obtained confidence intervals (CIs) for all estimates by bootstrapping more than 1000 resamples. We conducted all analyses in R version 4.2.2,30 and we fitted the models by using the stat, survival,31 and MASS32 packages.
RESULTS
In this study, we analyzed data from 9310 participants who completed lifetime and annual questionnaires between 2019 and 2021. Participants with missing data on age (n = 2), conversion practice recall (n = 22), gender identity (n = 1), and religious upbringing (n = 4) were excluded. Additionally, 7 participants were excluded who exclusively identified as White and Two-Spirit. This resulted in a final sample of 9274 participants (Table 1). Among the sample, 10.5% (n = 970) were minoritized ethnoracial cisgender, 9.6% (n = 888) were minoritized ethnoracial TNB, 44.5% (n = 4136) were White cisgender, and 35.4% (n = 3280) were White TNB.
Overall, 5.7% (n = 533) of participants recalled lifetime exposure to conversion practices, and 77.3% (n = 7169) reported a religious upbringing. Conversion practices prevalence was highest among minoritized ethnoracial TNB participants (8.6%; n = 76), followed by White TNB (6.3%; n = 207), White cisgender (5.0%; n = 206), and minoritized ethnoracial cisgender (4.5%; n = 44). The mean age of first exposure to conversion practices was 18.4 years (SD = 8.2), and the mean time from first to last episode was 3.1 years (SD = 6.1). Minoritized ethnoracial TNB participants experienced conversion practices at the youngest age (mean = 16.8 years; SD = 8.2), while minoritized ethnoracial cisgender participants experienced conversion practices for the longest period between the first and last exposure (mean = 4.3 years; SD = 8.8).
Among minoritized ethnoracial groups, lifetime recall to conversion practices ranged from 0% to 6.7% for cisgender participants and 5.4% to 19.0% for TNB participants (Table 2). The highest prevalence was among American Indian or Alaska Native TNB participants (19.0%). Multiracial cisgender and Middle Eastern or North African TNB participants were exposed to conversion practices at the youngest age, whereas American Indian or Alaska Native TNB participants had the longest period between their first and last exposure.
TABLE 2—
Conversion Practice Prevalence, Age of First and Last Exposure, and Time Between First and Last Exposure Among Cisgender and Transgender or Nonbinary Participants From Minoritized Ethnoracial Backgrounds: United States, 2019 to 2021
| No. | Lifetime Exposure, No. (%) | Age of First Exposure, Mean, Median ± SDa | Age of Last Exposure, Mean, Median ± SDa | Years Between First and Last Exposure, Mean, Median ± SDa |
|
| Cisgender | |||||
| American Indian or Alaska Native | 9 | 0 (0.0) | NA | NA | NA |
| Asian, Native Hawaiian, or Pacific Islander | 166 | 3 (1.8) | 20.3, 22.0 ± 5.7 | 21.3, 22.0 ± 4.0 | 1.0, 0 ± 1.7 |
| Black, African American, or African | 142 | 9 (6.3) | 19.6, 18.0 ± 9.5 | 23.2, 21.0 ± 10.2 | 3.7, 2.0 ± 3.9 |
| Hispanic, Latino, or Spanish | 377 | 19 (5.0) | 19.5, 17.5 ± 6.2 | 22.4, 19.0 ± 7.7 | 2.8, 1.0 ± 4.9 |
| Middle Eastern or North African | 15 | 1 (6.7) | NA | NA | NA |
| Multiracial | 261 | 12 (4.6) | 15.3, 15.0 ± 2.7 | 19.5, 16.0 ± 9.5 | 4.2, 1.0 ± 7.6 |
| Transgender and nonbinary | |||||
| American Indian or Alaska Native | 21 | 4 (19.0) | 18.8, 13.5 ± 14.5 | 28.8, 24.5 ± 20.6 | 10.0, 9.0 ± 10.7 |
| Asian, Native Hawaiian, or Pacific Islander | 112 | 6 (5.4) | 16.4, 16.0 ± 4.6 | 18.0, 16.0 ± 6.3 | 1.6, 0 ± 2.2 |
| Black, African American, or African | 82 | 7 (8.5) | 18.3, 14.0 ± 9.2 | 20.7, 16.0 ± 8.4 | 2.4, 0 ± 4.4 |
| Hispanic, Latino, or Spanish | 312 | 25 (8.0) | 15.9, 16.0 ± 7.3 | 18.6, 17.0 ± 6.1 | 2.7, 1.5 ± 3.6 |
| Middle Eastern or North African | 16 | 3 (18.8) | 15.5, 15.5 ± 2.1 | 17.5, 17.5 ± 5.0 | 2.0, 2.0 ± 2.8 |
| Multiracial | 345 | 31 (9.0) | 16.7, 16.0 ± 8.9 | 21.0, 18.0 ± 11.3 | 3.9, 2.0 ± 8.1 |
Notes. NA = not applicable.
Among participants who reported lifetime exposure to conversion practices (n = 533).
Adjusted log-binomial models indicated that minoritized ethnoracial TNB (PR = 2.16; 95% CI = 1.62, 2.86) and White TNB (PR = 1.57; 95% CI = 1.30, 1.92) participants had a higher conversion practice prevalence compared with White cisgender participants (Table 3). However, there was no significant difference between White cisgender and minoritized ethnoracial cisgender participants. Within the gender identity strata, minoritized ethnoracial participants had a higher conversion practice prevalence compared with White participants (PR = 1.38; 95% CI = 1.04, 1.75). Similarly, within the ethnoracial strata, TNB participants had a higher conversion practice prevalence compared with cisgender participants (PR = 2.14; 95% CI = 1.51, 3.19). There was also a positive additive interaction (RERI = 0.58; 95% CI = −0.04, 1.20), indicating that the joint effect of gender and ethnoracial identity is greater than the sum of their individual effects.
TABLE 3—
Estimated Differences in Lifetime Exposure, Age of First Exposure, and Period of Exposure for Conversion Practices by Ethnoracial Groups and Gender Identity: United States, 2019 to 2021
| Cisgender | Transgender and Nonbinary | Gender Identity Within Ethnoracial Strata | RERI (95% CI) | |
| Lifetime Exposure,a,b PR (95% CI) | ||||
| Minoritized ethnoracial | 1.01 (0.70, 1.39) | 2.16 (1.62, 2.86) | 2.14 (1.51, 3.19) | 0.58 (−0.04, 1.20) |
| White | 1 (Ref) | 1.57 (1.30, 1.92) | 1.57 (1.30, 1.92) | |
| Ethnoracial groups within gender identity strata | 1.01 (0.70, 1.39) | 1.38 (1.04, 1.75) | ||
| Age of First Exposure,b,c HR (95% CI) | ||||
| Minoritized ethnoracial | 0.96 (0.65, 1.34) | 2.04 (1.51, 2.69) | 2.13 (1.47, 3.21) | 0.60 (0.02, 1.21) |
| White | 1 (Ref) | 1.48 (1.20, 1.82) | 1.48 (1.20, 1.82) | |
| Ethnoracial groups within gender identity strata | 0.96 (0.65, 1.34) | 1.38 (1.04, 1.78) | ||
| Years Between First and Last Exposure,a,d CR (95% CI) | ||||
| Minoritized ethnoracial | 1.60 (0.95, 2.57) | 1.92 (1.14, 3.00) | 1.20 (0.63, 2.19) | −0.48 (−1.84, 0.67) |
| White | 1 (Ref) | 1.80 (1.28, 2.46) | 1.80 (1.28, 2.46) | |
| Ethnoracial groups within gender identity strata | 1.60 (0.95, 2.57) | 1.07 (0.64, 1.65) | ||
Note. CI = bootstrap confidence intervals using 1000 resamples; CR = count ratio; HR = hazard ratio; PR = prevalence ratio; RERI = relative excess risk due to interaction.
Models were adjusted for age (continuous), survey year, US Census division of residence, and religious upbringing.
Among all participants (n = 9281).
A step function was used to divide the data into 2 epochs for < 24 y and ≥ 24 y. Additional covariates adjusted in model included survey year, US Census division of residence, and religious upbringing.
Among participants who reported lifetime exposure to conversion practices (n = 533).
Kaplan-Meier curves are depicted in Figure 1, illustrating the unadjusted probability of not recalling exposure to conversion practices across each intersectional group. By age 18 years, the estimated probability was highest for minoritized ethnoracial cisgender (97.2%) and White cisgender (97.1%) individuals, followed by White TNB (95.6%) and minoritized ethnoracial TNB (93.5%) participants (log-rank P < .001). Adjusted Cox proportional hazard models indicated significant differences in the age to first exposure to conversion practices across intersectional groups. Both minoritized ethnoracial (HR = 2.04; 95% CI = 1.51, 2.69) and White (HR = 1.48; 95% CI = 1.20, 1.82) TNB participants had increased risk of conversion practices compared with White cisgender participants. There was no significant difference between White cisgender and minoritized ethnoracial cisgender participants. Furthermore, within the gender identity strata, minoritized ethnoracial participants had increased risk of conversion practices compared with White participants (HR = 1.38; 95% CI = 1.04, 1.78). Within the ethnoracial strata, TNB participants had increased risk of conversion practices compared with cisgender participants (HR = 2.13; 95% CI = 1.47, 3.21). Minoritized ethnoracial TNB participants experienced an “excess” increase in risk of conversion practices attributable to the intersection of gender and ethnoracial identity (RERI = 0.60; 95% CI = 0.02, 1.21).
FIGURE 1—
Kaplan-Meier Curve of Age at First Exposure to Conversion Practices by Ethnoracial Groups and Gender Identity: United States, 2019 to 2021
In the adjusted negative binomial model among participants exposed to conversion practices, both minoritized ethnoracial TNB (count ratio = 1.92; 95% CI = 1.14, 3.00) and White TNB (count ratio = 1.80; 95% CI = 1.28, 2.46) participants experienced significantly longer periods between first and last exposure to conversion practices. We detected no significant differences between White cisgender and minoritized ethnoracial cisgender participants or within the gender identity or ethnoracial strata. Additionally, there was no evidence of an interaction on the additive scale.
DISCUSSION
In this analysis of PRIDE participants, we found that minoritized ethnoracial TNB participants, particularly among American Indian or Alaska Native and Middle Eastern or North African participants, reported a disproportionate burden of conversion practice exposure. Specifically, living under systemic racism and cissexism, minoritized ethnoracial TNB participants had the highest conversion practice prevalence, were more likely exposed to conversion practices at a younger age, and experienced conversion practices for longer periods compared with cisgender participants and TNB participants of higher social privilege after adjusting for age, survey year, US Census division of residence, and religious upbringing. In addition, we observed heterogeneity among minoritized ethnoracial groups regarding the age of first exposure and period between first and last exposure, suggesting that gender and ethnoracial identity alone were insufficient to explain the joint disparity in conversion practices.18,33
Limited studies have evaluated conversion practice exposure across cross-stratified ethnoracial and gender groups; most have reported conversion practices among ethnoracial groups and gender identity separately.4–6,8,11 For example, in the Generations study, investigators reported that the prevalence of sexual orientation change efforts among sexual minority participants was about 7% overall, which was 5.8% among White and 8.1% among Black, Latinx, and other ethnoracial groups.4 In the US Transgender Survey, about 14% of transgender respondents reported being exposed to gender identity change efforts.6 In our study, we found that 5.7% of PRIDE participants recalled ever experiencing conversion practices. Across cross-stratified ethnoracial and gender groups, we found that conversion practice prevalence ranged between 0% and 19.0%. While these estimates are somewhat comparable to those from a recent systematic review,12 findings from this study extend the current literature by demonstrating how intersectionality can be used to evaluate the experiences with conversion practice of individuals at the intersection of multiple social identities, which was previously overlooked. These results also emphasize the need for greater attention in future research to how structural inequities such as racism and cissexism create adverse environments and contribute to the social patterning of conversion practice exposure and its harmful health consequences.4–6,8,11,34
A key finding is that The PRIDE Study participants first recalled exposure to conversion practice at a mean age of 18 years, which is younger than previously reported.34 The results further highlighted that minoritized ethnoracial TNB participants also reported the earliest age of initial exposure to conversion practice, and that there was a significant excess risk because of the intersection of racialized and gendered experiences. Further disaggregation by ethnoracial identity among cisgender and TNB participants suggested that the mean age of first exposure was 15.3 and 15.5 for multiracial cisgender and Middle Eastern or North African TNB participants, respectively, while American Indian or Alaska Native TNB participants experienced the longest average period between the age of first and last exposure. The younger age of exposure and longer duration could negatively impact the mental health and well-being of SGM participants, as conversion practice has been associated with suicidality across different age groups.4–8,11 In addition, these findings suggest that researchers should consider the contemporary and cumulative exposure to conversion practices to fully understand the life course and cumulative disadvantage associated with exposure to conversion practices.
Study Limitations
The results should be interpreted with consideration of several limitations. First, self-reported ethnoracial and gender identity may not fully encompass the extent of systemic racism and cissexism experienced by minoritized ethnoracial TNB participants. Second, White cisgender participants were selected as the reference group to be consistent with the theory of intersectionality; however, alternative approaches such as intersectional multilevel analysis of individual heterogeneity have been shown to be statistically efficient with smaller samples and do not require the selection of a reference group.35 Third, our outcomes were broadly defined and did not differentiate between the various forms of conversion practices, including the involvement of mental health professionals and religious leaders. Relatedly, questions on frequency of conversion practice exposure were not available; thus, we could not evaluate the actual duration of conversion practices over the observation period. Fourth, the lifetime survey did not capture the age at which participants first disclosed their gender identity or sexual orientation. Younger disclosure ages may increase the duration that participants are vulnerable to experiencing conversion efforts. Fifth, we lacked additional information regarding social and cultural context of participants who identified exclusively as White and Two-Spirit; thus, we presented both sets of results. Furthermore, our analysis primarily focuses on Two-Spirit as a gender identity, which may not accurately reflect the multidimensionality and spiritual traditions of Two-Spirit identity. Last, The PRIDE Study is a convenience sample of predominately White participants that relies on self-reported data and, therefore, may be subject to sampling, recall, and social desirability bias.
Public Health Implications
The United States has witnessed a rise in proposed and enacted antitransgender and anti-SGM legislation. This includes federal injunctions that prevent enforcement of conversion therapy bans and the absence of laws prohibiting conversion practices in 22 states.10 Against this socio-political backdrop, our findings suggest that TNB individuals, especially those from minoritized ethnoracial backgrounds, are more likely to experience prolonged exposure to conversion practices that occur at younger ages. This can exacerbate health disparities for individuals who face multiple forms of marginalization. Therefore, clinicians, researchers, and advocates should consider how conversion practice exposure and age of first exposure relates directly to health outcomes and differences in associations within and between intersectional groups. Finally, given the harmful effects and unethical premise of conversion practices, federal and local policies banning these practices can contribute to reducing the negative consequences of conversion practices in an equitable manner.
ACKNOWLEDGMENTS
This study was partially supported by the Gill Foundation.
The Population Research in Identity and Disparities for Equality (PRIDE) Study is a community-engaged research project that serves and is made possible by lesbian, gay, bisexual, transgender, queer, intersex, aromantic, asexual, and other sexual or gender minority community involvement at multiple points in the research process, including the dissemination of findings. We acknowledge the courage and dedication of The PRIDE Study participants for sharing their stories, the careful attention of the PRIDEnet Participant Advisory Committee members for reviewing and improving every study application, and the enthusiastic engagement of the PRIDEnet Ambassadors and Community Partners for bringing thoughtful perspectives and promoting enrollment and disseminating findings. For more information, visit https://pridestudy.org/pridenet.
Note. The funders 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 article; and decision to submit the article for publication.
CONFLICTS OF INTEREST
J. Obedin-Maliver has consulted for Hims Inc (2019‒present), Folx Inc (2020‒present), and Ibis Reproductive Health (2017‒present). M. R. Lunn has consulted for Hims Inc (2019‒present), Folx Inc (2020), and Otsuka Pharmaceutical Development and Commercialization Inc (2023).
HUMAN PARTICIPANT PROTECTION
The study was approved by the University of California San Francisco, Stanford University, and WIRB-Copernicus Group institutional review board, and now the WIRB-Copernicus Group institutional review board for ongoing analyses.
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