“They want you to kill your inner queer but somehow leave the human alive”: Delineating the impacts of sexual orientation and gender identity and expression change efforts

Abstract

Sexual orientation and gender identity and expression change efforts (SOGIECE) aim to suppress the sexual and gender identities of Two-Spirit, lesbian, gay, bisexual, trans, and other queer (2SLGBTQ+) people. Exposure to SOGIECE is associated with significant psychosocial morbidity. Yet, there is a dearth of knowledge specifying the ways in which these psychosocial impacts are produced and experienced. This qualitative interpretive description study aims to delineate the impacts of SOGIECE. To do so, we thematically analyzed data from in-depth interviews, conducted between January and July 2020, with 22 people with lived experience of SOGIECE. Study participants indicated that feelings of shame and brokenness related to their sexual and gender identities were deeply implicated in and shaped by experiences with SOGIECE. SOGIECE also had socially isolating effects, which had restricted participants’ opportunities for meaningful connection with others, including romantic partners and 2SLGBTQ+ communities. Further, SOGIECE had contributed to experiences of profound emotional distress, mental illness (e.g., anxiety, depression), and suicidality. These findings underscore the need for several responsive policy and programmatic interventions, including legislation to prevent SOGIECE, enhanced sexuality- and gender-related educational efforts with the families and support persons of 2SLGBTQ+ people, and targeted mental health screening and supports for SOGIECE survivors.

Introduction

In Canada and internationally, communities of Two-Spirit¹, lesbian, gay, bisexual, transgender, and other queer (2SLGBTQ+) people and allies have rallied together in long and hard-fought movements to be recognized, accepted, and celebrated in society (Mulé et al., 2009; Pruden & Salway, 2020; Smith, 1999; Warner, 2002). Yet, 2SLGBTQ+ people continue to experience significant systemic oppression, including stigma, discrimination and violence (Mulé, 2015). This oppression is particularly evident in the historical and continued occurrence of sexual orientation and gender identity and expression change efforts (SOGIECE), commonly referred to as “conversion therapy” and “reparative therapy.” SOGIECE constitute a variety of practices that aim to deny or suppress feelings and desires related to non-heterosexual identities, as well as expressions of gender and gender identities that differ from one’s sex assigned at birth (Salway, 2020a; Shidlo et al., 2001). SOGIECE are known to contribute to significant psychosocial harms, including mental health morbidity. For example, recent national surveys of 2SLGBTQ+ people in Canada and the United States have indicated that exposure to SOGIECE is associated with loneliness, regular illicit drug use, suicidal ideation, and attempted suicide (Salway et al., 2020; Turban, Beckwith, et al., 2019). Despite these well-documented harms, SOGIECE remain critically under addressed in public health research and policy spheres and continue to occur internationally – affecting an estimated 3–18% of 2SLGBTQ+ people, according to population-level surveys in the United States and Canada (Green et al., 2020; Mallory et al., 2019; Meanley et al., 2019; Caitlin Ryan et al., 2020; Salway et al., 2020; Trans PULSE Canada, 2019; Turban, Beckwith, et al., 2019; Turban, King, et al., 2019).

SOGIECE became more pervasive in North America following the American Psychiatric Association’s removal of homosexuality as a mental disorder from its 1973 edition of its Diagnostic and Statistical Manual of Mental Disorders (Shidlo et al., 2001). This institutional change, alongside improving societal attitudes and discourses related to gender and sexuality, signaled important advancements in 2SLGBTQ+ people’s rights and recognition. However, reforms such as these also incited and catalyzed efforts to scale up SOGIECE across a variety of contexts (e.g., faith-based, healthcare; from unregulated counsellors) (Salway et al., 2020; Shidlo et al., 2001). SOGIECE were initially promoted under the guise of interventions that could suppress or repress same-sex attraction, but they are also often targeted toward denying and/or subduing gender identities and expressions that do not align with one’s sex assigned at birth (Byne, 2016; Minister of Justice, 2020). These efforts, regardless of their forms and “targets,” both stem from and assert the erroneous ideology that being queer and/or transgender (trans) is fundamentally incompatible with leading a healthy and fulfilling life (Salway, 2020b).

SOGIECE draw on a number of ineffective and discredited techniques, including aversion therapies (e.g., electric shock), psychodynamic therapies (i.e., which intend to identify and address the perceived etiology of one’s sexuality and/or gender, such as overbearing or distant parent and sibling relationships), biomedical and clinical practices (e.g., hormonal treatments, denial of gender-affirming care and surgeries), and religious and spiritual practices (e.g., guided prayer, Bible reading, exorcisms) (Salway et al., 2020; Shidlo et al., 2001). Forms of SOGIECE also vary in intensity and scope. And, while SOGIECE are directly related to and constitutive of more organized and sustained sexual and gender identity suppression efforts (e.g., “conversion therapy”), SOGIECE may also include practices that are less well defined, advertised, and/or sustained (Salway, 2020a). At present, data are lacking on the precise settings, scale, and manners in which SOGIECE are conducted. Nonetheless, we do know that experiences of SOGIECE are ongoing and highly prevalent among 2SLGBTQ+ people (Green et al., 2020; Mallory et al., 2019; Meanley et al., 2019; Caitlin Ryan et al., 2020; Salway et al., 2020; Trans PULSE Canada, 2019; Turban, Beckwith, et al., 2019; Turban, King, et al., 2019).

Public awareness of and response to the continued occurrence of SOGIECE in Canada and internationally has tended to lag behind scientific research into its prevalence and impacts (Salway et al., 2019). Indeed, a recent international report (Bishop, 2019) detailed that SOGIECE continue to occur nearly everywhere in the world; yet, only five countries – Brazil, Ecuador, Malta, Taiwan, and Germany – have national conversion therapy bans in place (Bishop, 2019; OutRight Action International, 2020). Fortunately, enhanced efforts to ban conversion therapy are presently underway in many countries and sub-national jurisdictions (Bishop, 2019). For example, in Canada, four of the country’s 13 provinces and territories and several additional municipalities have banned conversion therapy (d’Entremont, 2020), and there are ongoing efforts to introduce a national ban through amendments to Canada’s Criminal Code (Department of Justice Canada, 2020). In tandem with such efforts, however, is a critical need to identify and implement strategies for supporting the health and wellbeing of people who have experienced and/or who are still experiencing SOGIECE.

Few studies have undertaken in-depth investigation into how SOGIECE may impact mental health and social wellbeing. The available qualitative evidence related to SOGIECE is largely focused on the United States context (Flentje et al., 2014; Johnston & Jenkins, 2006; Shidlo & Schroeder, 2002), but nonetheless suggests that people who have experienced SOGIECE tend to view these practices as ineffective and harmful. These studies identified that a minority of people find some benefit in SOGIECE, such as finding connection and support with peers in similar situations (Flentje et al., 2014; Shidlo & Schroeder, 2002), but that these benefits are vastly outweighed by the harmful aspects of SOGIECE, including experiences of shame, self-loathing, and deterioration in mental health (Flentje et al., 2014; Johnston & Jenkins, 2006; Shidlo & Schroeder, 2002). Still, less is known about the distinct ways in which these harms are produced and experienced – a prudent knowledge gap, given that SOGIECE continue to occur across the globe. Action-oriented and community-led research efforts that center people with lived experience are needed to fill existing knowledge gaps and, ultimately, to redress the harms of SOGIECE. The aim of this study is therefore to delineate the emotional, social, and mental health impacts associated with SOGIECE, as well as the significance and meaning ascribed to these impacts, as described by people with lived experience.

Method

Positionality

We approach this study as public health researchers and clinicians (e.g., nursing, social work), and also as people with lived experience of being queer and/or of allyship to 2SLGBTQ+ communities. It is from this liminal standpoint that we hold the evidence- and equity-informed assumption that SOGIECE are fundamentally harmful, though we recognize this stance may be counter to the experiences and perspectives of others. It also from this standpoint that we seek to foster health equity by accentuating the adverse impacts of SOGIECE, and, responsively, to identify strategies for promoting equitable health, healthcare, and social wellbeing for people who have experienced SOGIECE. We aim to do so by drawing on the knowledge and resilience of a sample of 2SLGBTQ+ people with lived experience of SOGIECE, which we seek to mobilize into critical public health action through our own research activities, interpretations, and data-driven and community-informed policy and programmatic recommendations.

Study overview

This qualitative study was guided by interpretive description, an inductive and pragmatic methodology for constructing and synthesizing practice-oriented findings (Thorne, 2016). Interpretive description approaches are well suited to developing an understanding of what should occur to advance policy and practice within situation- or phenomenon-specific healthcare contexts (Thorne, 2016). This study draws on interpretive description to first elucidate a nuanced understanding of the impacts of SOGIECE described by those who have experienced it firsthand, and, second, to draw from these interpretations to identify priorities for improving health policy and practice within this substantive context. We also draw on a social constructivist epistemology (Charmaz, 2014; Weaver & Olson, 2006), which enables us to provide rich descriptions of these impacts while preserving the complexity of the social contexts in which they occur. This paradigmatic approach facilitates a more fulsome exploration of the social meaning participants ascribe to the impacts of SOGIECE, the social conditions and processes through which these impacts unfold (e.g., when, how, with whom, to what effect), and the socio-political and subjective contexts in which we, as researchers, situate and interpret these impacts. Here, we also employ a critical theoretical framework underpinned by values of health equity and social justice (Browne & Reimer-Kirkham, 2014; Varcoe et al., 2014) to direct attention to the structurally embedded nature of SOGIECE. It is through this lens that we view SOGIECE as a product of societal inequities (e.g., queerphobia, stigma, violence) facing 2SLGBTQ+ people, and, further, that we seek to interpret the impacts of SOGIECE within the structural contexts of participants’ lives (e.g., related to: community belonging, employment, health and healthcare access).

Sampling and recruitment procedures

We purposively sampled (Palinkas et al., 2015) 2SLGBTQ+ people with lived experience of SOGIECE to obtain a comprehensive and multifaceted account of the impacts associated with these practices. Study participants were recruited from across Canada through advertisements shared via community and research partner social media posts. We engaged partner organizations (e.g., Generous Space, Community-Based Research Centre) with specific foci and/or service-user demographics to share our study advertisements, with a view to both facilitate recruitment and maximize the gender, sexual orientation, and racial/ethnic diversity of participants with lived experience of SOGIECE. It is noteworthy that our recruitment strategies and study advertisements reflected our research team’s stance that SOGIECE are harmful; for example, our advertisements indicated our desire to hear from “survivors” of SOGIECE. Participants were eligible for inclusion if they were 19 years of age and older, lived in Canada, spoke and understood English or French, and had directly experienced SOGIECE at any time in their life.

All participants provided informed consent prior to data collection activities. Participants were remunerated with a CDN $50 honorarium. Approval for this study was obtained from Research Ethics Boards at Simon Fraser University (#2019s0394) and Université de Montréal (#CERSES-20–048-D).

Data collection

Between January 31 and July 29, 2020, we conducted in-depth, semi-structured interviews that lasted 60–120 minutes each. Participants also completed a 13-item socio-demographic questionnaire. We held a subset of interviews in person at our research offices in Vancouver and Toronto, though most interviews were conducted remotely using audiovisual platforms (e.g., Skype, Zoom). Interview questions were designed to elicit rich and comprehensive discussions of participants’ perspectives, experiences, and contexts of SOGIECE. We approached the interviews with a sense of openness and flexibility, including when we asked participants to describe any health and social impacts they attributed to SOGIECE. Here, the primary interview question underpinning the current analysis was: “How do you feel your experience with SOGIECE has affected you?” As participants responded to this question, they were encouraged to elaborate on the ways in which SOGIECE may have affected their relationships with various people and communities in their lives, including their biological families, faith-based communities, 2SLGBTQ+ communities, and romantic and sexual partners. Likewise, participants were prompted to describe how various social and contextual features of their lives (e.g. relationships, health and social service engagement, employment, moving and other life transitions) influenced their experiences before, during, and following SOGIECE. Reflexive field notes were completed following each interview.

Sample demographics

We recruited a diverse sample (Table 1) of 22 participants who ranged from 20 to 64 years of age. Participants lived across Canada, including in the provinces of British Columbia (9.1%), Alberta (18.2%), Manitoba (4.6%), Ontario (45.5%), Quebec (18.2%), and New Brunswick (4.6%). In the socio-demographic surveys, participants identified as cisgender (77.3%), trans (18.2%), and – for one participant – “not sure” (4.6%). Participants also reported a spectrum of gender identities, including man (77.3%), woman (18.2%), non-binary (13.6%), and/or genderfae (4.6%), with some participants reporting multiple and/or fluid gender identities (e.g., one participant identified as both a woman and as a non-binary person; another participant identified as non-binary, genderfae, and a woman). Most participants identified as gay (68.2%) or queer (22.7%), though participants also identified as bisexual, pansexual, and/or straight. One participant described his sexual identity as “attracted to men, but not gay.” One participant identified as Two-Spirit. Participants tended to describe having experienced SOGIECE within faith-based and/or healthcare contexts, with 72.7% of participants reporting that their experiences with SOGIECE had lasted more than one year. The majority (86.3%) of participants also indicated that they had first experienced SOGIECE in adolescence and/or as young adults (<30 years of age).

Table 1:

Characteristics of in-depth interview participants, January-July 2020, Canada

Participants	22
Age (mean, range)	38.7 (20–64 years)
Age category
20–29	6 (27.3%)
30–39	6 (27.3%)
40–49	5 (22.7%)
50–59	4 (18.2%)
60–64	1 (4.6%)
Age at first SOGIECE experience
<17	7 (31.8%)
18–29	12 (54.6%)
>30+	3 (13.6%)
Gender identity 1
Woman	4 (18.2%)
Man	17 (77.3%)
Non-binary	3 (13.6%)
Genderfae 2	1 (4.6%)
Transgender
Yes	4 (18.2%)
No	17 (77.3%)
Not sure 3	1 (4.6%)
Sexual orientation 4
Bisexual	3 (13.6%)
Gay 5	15 (68.2%)
Pansexual	1 (4.6%)
Queer	5 (22.7%)
Straight	1 (4.6%)
Other 6	1 (4.6%)
Two-Spirit
Yes	1 (4.6%)
No	21 (95.4%)
Race/ethnicity
Arab	1 (4.6%)
Black	1 (4.6%)
First Nations	1 (4.6%)
Multi-racial	1 (4.6%)
Southeast Asian	1 (4.6%)
White	17 (77.3%)
Province of residence
Alberta	4 (18.2%)
British Columbia	2 (9.1%)
Manitoba	1 (4.6%)
New Brunswick	1 (4.6%)
Ontario	10 (45.5%)
Quebec	4 (18.2%)
Interview language
English	19 (86.4%)
French	3 (13.6%)

¹Some participants selected more than one gender identity.

²“Genderfae” is a term used to describe a form of genderfluidity that does not include masculine genders.

³One participant indicated “not sure” when asked if they identified as trans, during the socio-demographic survey.

⁴Some participants selected more than one sexual orientation.

⁵Study participants of diverse genders identified as gay.

⁶One participant identified his sexual orientation as “attracted to men, but not gay.”

Data analysis

Interviews were audio-recorded, transcribed verbatim, checked for accuracy, and anonymized. We then organized and managed the transcripts using NVivo 12 software. Data analysis followed the logic of interpretive description (Thorne, 2016) in that our approach was iterative and oriented toward constructing findings that have implications for policy and practice. Our reflexive field notes and guiding analytic questions therein prompted intentional engagement with the data as they were being collected. Further, this field noting facilitated critical self-reflection into pertinent aspects of the interviews (e.g., emergent and unanswered questions, interviewer ruminations, novel and/or contrasting findings), which informed subsequent data collection and analysis, such as through the inclusion of additional interview questions and prompts. Preliminary data immersion and analysis also included reading and re-reading participant transcripts, and debriefing participant interviews at research team meetings. We matured our analysis by coding the data, which occurred nearly simultaneously with data collection, with some lag time for transcription. Here, three research team members open-coded an initial subset of the transcripts by organizing the data into patterns, creating substantive codes that reflected key aspects of the phenomena described by study participants (e.g., “mental health,” “identity,” “shame”), and discussing and reconciling the codes used, including through debriefing processes with the broader research team. Remaining transcripts were coded thereafter.

The analysis drew on social constructivist techniques used within interpretive description and grounded theory (Charmaz, 2014; Thorne, 2016) to gradually transform the coded data into thematic findings. This process included a series of inductive strategies, including collapsing our codes, reflecting on our study research questions, returning to the data for nuance and context, engaging with relevant empirical and theoretical literature, and revisiting the content and questions posed in our field notes. We also engaged with the following guiding analytic questions to focus and refine the analysis: (i) How do participants describe the impacts of having experienced SOGIECE? (ii) In what ways are the impacts of SOGIECE differentially characterized across and within participants’ stories (e.g., immediacy, duration, and severity of impacts)? (iii) How do SOGIECE and their impacts interact with the social contexts of participants’ lives? This focused engagement with the data supported us to further synthesize and construct the findings into central themes. Below, we summarize our findings holistically and subsequently provide an in-depth presentation of our central themes. Here, we also include illustrative quotations that highlight key thematic features and provide additional context for interpretation.

Results

The deleterious emotional, social, and mental health impacts of SOGIECE

The way participants perceived and described the impacts of SOGEICE can be divided into three interconnected themes: (i) feelings of brokenness and wanting to be whole, (ii) social and relational consequences, and (iii) impacts on mental health and wellbeing. We describe these themes sequentially; however, movement through and between them is intended to be nonlinear, given their interconnectedness. First, participants described how SOGIECE had reinforced feelings of brokenness and wanting to be whole, which, for many participants, contributed to challenging starts to their adult lives. Second, participants described how life within non-affirming contexts of SOGIECE had precipitated significant social and relational hardships, including, in particular, social isolation and challenges connecting to others (e.g., romantic and sexual partners, 2SLGBTQ+ communities, families). Third, participants described how SOGIECE had been particularly harmful with respect to mental health and wellbeing, including through reinforcing feelings of guilt and shame related to one’s sexual and gender identities. Here, participants indicated that the profound mental health consequences of SOGIECE, including suicidality and debilitating mental illnesses (e.g., depression, anxiety), had been long-lasting and, in many cases, were still present. Taken together, it is our interpretation that the impacts of SOGIECE are predominantly negative and severe, to a point of being life threatening.

It is noteworthy that only one participant in this sample described their experience with SOGIECE favourably. Whereas this participant described himself as a “conversion therapy thriver,” due to the perceived support and religious affirmation he received during SOGIECE, all other participants characterized SOGIECE as ineffective and detrimental to their mental health and social wellbeing. This outlier participant also indicated that his experience with SOGIECE had not been “effective,” as he still experiences “same-sex attraction” but fills this desire with his religious faith. This participant nonetheless described being staunchly supportive of SOGIECE, particularly with regard to an individual’s right to choose whether or not to attend SOGIECE. Given the unique disposition of this participant, and the research questions posed, we have excluded this data from the present analysis, while acknowledging that his experience and those of other “conversion therapy thrivers” may merit a separate investigation.

Feelings of brokenness and wanting to be whole: “Something wrong that needs to be fixed”

Participants in this study described having experienced various “types” of SOGIECE, including formalized individual and group counselling sessions (e.g., with faith leaders and/or healthcare providers; at conversion therapy camps and/or retreats), other faith-based practices (e.g., guided prayer sessions, exorcisms), and more general experiences of queerphobia in which participants were pressured to repress their sexual and gender identities. Taken together, participants described how SOGIECE had induced feelings of shame and confusion related to their sexual and gender identities – feelings that, in many cases, participants indicated were ongoing. Participants further described how SOGIECE had caused them to feel inferior or “broken” because of their non-normative sexual and gender identities. Participants often described how, even before they had experienced SOGIECE, the process of coming to understand and accept their sexual and gender identities had been both challenging and distressing – particularly, for participants who had grown up in highly cisheterosexist and non-affirming contexts. Regardless of when participants’ “struggles” began and the intensity of cisheterosexist messaging they had encountered in their early lives, SOGIECE were described as having greatly exacerbated feelings of distress. As one participant described:

[Growing up], the single message that I kept tucked away in my soul, I guess, was that I was broken and needed to be made complete and whole. So, then of course, as long as I am having gay thoughts, I’m still broken. [SOGIECE] doesn’t do a lot for one’s self-image, one’s recognition, it doesn’t do much even for a person’s understanding of being a Christian (60- to 64-year-old man who identifies as gay).

Participants also described how SOGIECE had been deeply detrimental to their self-image and self-esteem, as illustrated in above quotation. Here, participants described how SOGIECE practitioners (e.g., healthcare providers, faith leaders) had consistently told them that their sexual and gender identities were incompatible with the norms, values, and expectations of the communities in which they lived. This sort of messaging throughout participants’ experiences with SOGIECE was described as exceedingly harmful in that it had precipitated intense feelings of confusion and isolation. Often, participants described how SOGIECE had sparked feelings of being “damaged” and like an “outsider.” Participants often juxtaposed this SOGIECE-induced dysphoric mindset with the sexual and gender identity-related affirmation and “healing” they had hoped to secure. For instance, one participant described how:

[I had] that concern within me, that what I’m feeling is wrong, I’m broken, and this needs to be healed. […] But, [I was] never really getting any resolution [in SOGIECE]. It just created more turmoil within me (40- to 49-year-old person who identifies as queer, gay, non-binary, and a woman).

Participants offered rich descriptions of the ways in which SOGIECE had aggravated feelings of inner turmoil and “brokenness”. Here, participants described having held the belief that there was something fundamentally “wrong” with them – something they had been coerced into thinking was in need of repair for them to feel “whole.” Frequently, participants described how SOGIECE practitioners and organizations had positioned themselves as being capable of effectively supporting participants to subdue their sexual and gender identities. Many participants described feeling as though they had been given a sense of “false hope” because SOGIECE had not, in fact, been “helpful;” rather, SOGIECE were described as having been acutely damaging with respect to overall health and wellbeing. In this regard, one participant offered:

[What] really stuck out to me is this idea, not necessarily about solely sexual orientation, or gender identity, or those things, but about this idea that you are teaching a person that there is something wrong with them that needs to be fixed. And that the [SOGIECE] therapist is the one who can do that (30- to 39-year-old woman who identifies as bisexual and trans).

Participants also described how SOGIECE had evoked intense feelings of shame and guilt, which further reinforced feelings of “brokenness.” Participants tended to describe a distinct sense of self-blame and regret over having “voluntarily” attended SOGIECE. Indeed, although participants described that SOGIECE necessitated some degree of support or coercion from outside influences (e.g., family members, healthcare providers, religious leaders, societal pressures), many nonetheless identified their own perceived role in attending SOGIECE as a particularly painful source of regret and injury. Here, participants often described having hoped that SOGIECE would help them to feel “whole” or “normal.” Yet, as participants elaborated, they described how SOGIECE had had the opposite effect in that these practices had only reinforced feelings of inferiority. One participant described the complex and lasting nature of the detrimental impacts associated with SOGIECE, including with regard to SOGIECE-related expectations and shortcomings:

I was very, very involved. I really wanted it [SOGIECE] to work, and I think that’s why it was so damaging for me, because I put everything I had into it… And I put all my hope and my belief into it, and moving away from that was also very difficult, because the shame and the guilt lingered for a very long time (20- to 29-year-old non-binary person who identifies as queer).

Participants described the ways in which their experiences with SOGIECE had intersected with key transitional periods in their lives, including times in which they had been “coming out” (i.e., disclosing their sexual and gender identities to others) and, more generally, growing into adulthood and themselves (i.e., “coming in”). Here, participants described how certain SOGIECE-related harms, and periods of SOGIECE and harm, were more lasting and more difficult to remedy than others. Among participants who identified as trans, many described how SOGIECE generally, and denial of access to gender-affirming care (e.g., hormone replacement therapy) and surgeries specifically, had led to enduring physical consequences. Of note, a subset of participants described how being refused gender-affirming care during adolescence was particularly damaging, as this precipitated the development of unwanted and long-lasting physiological changes associated with puberty and the sex they had been assigned at birth. This description of how SOGIECE can result in a mismatch between participants’ physical bodies and their gender identities offers, quite literally, a poignant illustration of how these practices inhibit opportunities for participants to truly feel and be “whole.” In recounting having been compelled to undergo sex-related bodily changes that did not align with her gender identity and expression, one participant described:

I’d had this continued growth and this change, and that I had asked him [the psychiatrist] to stop this [puberty, through puberty-blocking medications], but he had refused to do so. And, this is honestly one of the hardest parts of the aftermath of the conversion therapy to deal with. And, the usual term I use is that I think of my body as a prison, because it was the conversion therapist’s deliberate inaction that forced me into a body that doesn’t fit me and that I’m going to be stuck in for the rest of my life (30- to 39-year-old woman who identifies as bisexual and trans).

Social and relational consequences: “Lost time” and “feeling unclean”

Participants described the ways in which SOGIECE had precipitated a series of unfavourable effects across their social contexts and interpersonal relationships. Pervasive experiences of having their identities discredited and suppressed through SOGIECE had led participants to experience social isolation and feelings of lack of belonging. Participants often described how this “outsiderness” had largely begun in early childhood and with their families and communities of origin, but was later amplified and/or solidified through their experiences with SOGIECE. As participants elaborated, many referenced the specific processes through which SOGIECE practitioners had endeavoured to suppress participants’ sexual and/or gender identities, including through the (mis)use of faith-based messaging that positioned religion and queerness as incompatible. This bombardment with anti-2SLGBTQ+ messaging was described by participants as having intensified pre-existing feelings of loneliness and lack of belonging. In describing this sense of disconnect and “othering,” one participant offered this analogy:

I always identified with those [biblical] characters that had leprosy, because they were left out on the fringe of town, they weren’t allowed to touch anyone, they weren’t allowed to get close to anyone. And, if they did go into town, they had to announce that they were unclean the whole time that they were there, and I always felt that that was a powerful metaphor (40- to 49-year-old man who identifies as bisexual).

Relatedly, participants described feeling as though SOGIECE had, to varying degrees, impaired their motivations and opportunities for social connection with 2SLGBTQ+ communities. Participants frequently described how SOGIECE-associated key messages that equated 2SLGBTQ+ identities with undesirable “lifestyles” or even “diseases” had undermined their capacity to meaningfully connect with other 2SLGBTQ+ people, despite their strong desire to do so. Here, participants tended to describe how internalized anti-2SLGBTQ+ sentiments – particularly, those reinforced through SOGIECE – had contributed to participants’ active rejection of 2SLGBTQ+ communities. Indeed, although the majority of participants described having eventually found meaningful connection with other 2SLGBTQ+ individuals, they nonetheless described how affiliating themselves with 2SLGBTQ+ communities and events (e.g., Pride, nightclubs, sport and other hobby groups) had, at times, precipitated intense feelings of shame, guilt, and fear. Participants further described how these adverse feelings had precipitated a sense of social isolation and disconnect from 2SLGBTQ+ communities, which was described as having persisted for years following SOGIECE, preventing participants from living full and authentic lives:

I’m just thinking of, I guess, the years I just spent in fear and not pursuing relationships. I remember having this vivid idea of, I guess, as this person who was very in the closet, I felt like I was standing at a door. There was a window in the door, there was this party going on, you know this LGBTQ party, and I’m just standing there at this door looking in and terrified to enter and, you know, there’s this party happening and I kind of want to go in but I’m terrified, and if I go in, it’s a slippery slope and am I on my way to hell in a handbasket, kind of a thing! So, all those years I spent at that door looking in. (40- to 49-year-old man who identifies as gay).

Many participants elaborated that, as a result of SOGIECE, they experienced significant challenges initiating and sustaining romantic relationships. Non-heterosexual participants described how SOGIECE had suppressed and limited their opportunities to learn about and experiment with relationships that aligned with their sexual orientations. Often characterized within these descriptions were feelings of shame, fear, and concern related to the acceptance and outward display of participants’ queer sexualities. SOGIECE deeply accentuated these emotions, as one participant described:

I find it difficult, particularly in my relationship with my partner, I think, to be open and honest and communicate what my [sexual and romantic] preferences are, in certain ways, because I don’t know what they are! I feel like conversion therapy basically said what I want or desire should not be engaged in, like, you shouldn’t do that, like, you have the same-sex attraction but you should not go forward in that. That needs to be repressed in some way (40- to 49-year-old person who identifies as queer, gay, non-binary, and a woman).

Amidst these descriptions, participants highlighted that, after having been exposed to SOGIECE, sexual activity could sometimes be challenging and emotionally triggering. Participants described instances in which sexual and intimate encounters following SOGIECE were tainted by the unwelcome provocation of strong, SOGIECE-driven feelings of guilt and shame. This emotional distress was characterized as having stemmed from the negative and sexually repressive messages to which participants were repeatedly exposed in SOGIECE. As one participant explained:

The last boyfriend that I had, he cried a lot when I told him about it [my experience with SOGIECE], right. But then, when I was like, “No, we can’t like fool around tonight,” or, “I can’t let you like give me a blowjob tonight, because I can’t deal with what will happen to me mentally afterwards,” that’s different. So, it’s one thing to know that like the person that you love, from their perspective, has gone through this. It’s another thing to have it impact you in the bedroom. (40- to 49-year-old man who identifies as gay).

More generally, participants tended to describe an opportunity cost in which they had experienced “lost time” as a result of experiences with SOGIECE and therefore had fewer opportunities to pursue romantic relationships. Amidst these descriptions, participants frequently referred to the ways in which SOGIECE had pressured them to repress their sexual and gender identities, which, in many cases, included an emphasis on abstaining from “same-sex” relationships and sexual activities. Many participants described how this repression of sexual and relational desires had persisted internally for years after exposure to SOGIECE. At the time of our interviews, participants even described an apprehensiveness that they may not be “successful” in terms of pursuing and settling into supportive, romantic partnerships in the years ahead. Characterized within these descriptions was a sense that, after extensive exposure to anti-2SLGBTQ+ messaging during SOGIECE, some participants went on to perceive themselves as too ashamed, afraid, and/or “broken” to become romantically involved with others. These relational barriers tended to surface amid participants’ descriptions of their relationship-related hopes and goals, wherein many participants also perceived romantic partnerships to be fundamental to realizing life quality and fulfillment. Here, the prospect of continued experiences of loneliness and social and romantic isolation following SOGIECE was described as particularly disheartening. When asked about his hopes and plans for the future, one participant described:

[I worry that], in later age, I would be alone, miserable, and there will be no one here to look after [me]. So, these consequences, these repercussions, or the period of time as I get older, [they] haunt me most of the time, you know? (40- to 49-year-old man who identifies as gay).

Impacts on mental health and wellbeing: “A very dark period in my life”

Participants offered rich descriptions of the ways in which SOGIECE had negatively impacted their mental health and wellbeing. Characterized within these descriptions was a common perception that one’s overall sense of self, including with regard to core beliefs and identities targeted by SOGIECE, is intricately connected with how one experiences health and quality of life. Thus, while SOGIECE were described as having been targeted toward “fixing” various aspects of participants’ sexual and gender identities (e.g., romantic attraction, sexual desires, gender identity and expression), such efforts were also perceived to have had tangible and deleterious health impacts, particularly in relation to mental wellbeing. In drawing attention to the intersection between SOGIECE and health, one participant succinctly described:

It ties into that [belief], like, how basically this sin in your life was what Christ had to die for. And that’s why you have to die to this sin, and so you basically have to kill it in you. Like, they want you to kill your inner queer but somehow leave the human alive! (40- to 49-year-old man who identifies as bisexual).

Participants described how claims related to the effectiveness of SOGIECE, as well as the tactics and approaches used in SOGIECE themselves, had instilled feelings of inadequacy and a sense of personal failure (implied by the above participant’s assertation that SOGIECE practitioners put the onus on the individual to “kill [their] inner queer”) that were greatly distressing. Many participants further described feeling as though they were a disappointment to others (e.g., family members, faith-based communities), whom they perceived to be “letting down” as a result of their sexual and gender identities, and also due to ceasing attendance in or not being “successful” (i.e., at subduing their sexual and gender identities) in SOGIECE. Here, participants described how SOGIECE-reinforced perceptions of being a “failure” and/or “broken” (i.e., because of their sexual and gender identities) had deleteriously impacted their self-esteem, self-confidence, and overall mental wellbeing. In underscoring the emotional hurt caused by efforts to suppress his sexual orientation, one participant described:

It makes you feel like so much more of a failure. It’s like, oh, other people could do it, they prayed hard enough, why can’t I pray hard enough? (20- to 29-year-old man who identifies as queer and gay).

Many participants also described how their experiences with SOGIECE had provoked a great deal of anxiety and dread. Here, participants tended to describe how attending SOGIECE was, by and large, an energy-draining and damaging experience. For the majority of participants, the stress induced by SOGIECE was exacerbated by broader efforts to conceal their sexual and gender identities from family members and their communities. Participants detailed a variety of coping strategies for managing these negative emotions, including some maladaptive strategies such as using alcohol, cannabis, and cigarettes as means for coping with the effects of SOGIECE. One participant described the relationship between his sexuality, SOGIECE, and substance use:

There was sort of a level of tension and energy sort of like, I don’t know, maintaining a facade or trying suppress it [my sexuality], exactly, I don’t know how much I tried to suppress it. I guess there was a level of tension and anxiety that just, sort of, just [was] kind of a constant state of being. […] I drank a lot, I struggled with alcohol I guess most of my adult life on and off, and I don’t know how directly, I’m sure that they’re related, but there are probably other things that have impacted that (50- to 59-year-old man who identifies as gay).

Participants also described the ways in which SOGIECE had contributed to feelings of hopelessness and despair, both with regard to their present circumstances in SOGIECE and their future outlooks on life. Here, participants described how the heavy emotional burden of life within a SOGIECE context had taken a toll on their mental health. Indeed, participants overwhelmingly characterized SOGIECE as having contributed to significant mental distress through repeated instances of disaffirmation. Participants further described how this emotional distress had deeply impacted their life-course trajectories, including with regard to access to educational and employment opportunities. For example, a subset of participants described how the emotional damage done through SOGIECE had been so burdensome that, even after their experiences with SOGIECE had come to an end, they remained too unwell to work and/or pursue their educations. One participant described her mental health-related disability following SOGIECE:

A lot of it was depression and anxiety arising from that. So, I was a mental health case who needed help. […] I just hit rock bottom and just stayed there, in a severe depression, for probably about a good half decade honestly. There was a half-decade of my life where I was just living in my mom’s basement. I was completely disabled – I would spend most days just in bed. I was not good or useful or able to function in any way (30- to 39-year-old woman who identifies as bisexual and trans).

For a subset of participants, experiences with SOGIECE were described as key contributors to specific healthcare provider-diagnosed mental illnesses, including anxiety disorders, mood disorders, and post-traumatic stress disorder. Most commonly, participants described experiencing depression and depressive symptoms due to the cumulative emotional toll of SOGIECE. Participants with brief exposure to SOGIECE tended to characterize this depression as acute and short-lived, while those with longer or more traumatic exposure to SOGIECE often described having become depressed for prolonged periods of time. In describing their emotional state following an intensive series of SOGIECE, one participant reflected:

They made me really, really depressed. They made me feel like I was failing, they made me feel like I’m not trying hard enough, because to me it all made sense and I just had to kind of apply myself to this program. But, it wasn’t working! And so, it was kind of like my last little glimmer of hope was dissipating and I had nothing else to rely on, and I was just going to be super unhappy for the rest of my life, because I couldn’t do this… So, I kind of took it as a personal failure. Eventually, that led to a very dark period in my life where I was suicidal and just things were not going well (20- to 29-year-old non-binary person who identifies as queer).

Several participants experienced suicidal thoughts before, during, and after their SOGIECE experiences. The suppression of one’s sexual and/or gender identities through SOGIECE was revealed to be a particularly influential contributor to suicidality. Participants often characterized feelings of social isolation, hopelessness, and despair related to their experiences with SOGIECE as key causes of their desire to end their lives. Participants tended to associate their experiences with suicidality to SOGIECE in a broad sense. Here, many participants indicated that severe declines in mental health – to a point of being suicidal – had been the “final straw” that led them to cease taking part in SOGIECE. Participants also went on to describe how specific SOGIECE-related moments, periods, and methods had been especially egregious in terms of provoking thoughts of suicide. This “out” through suicide was sometimes even described by participants to be more fathomable than the alternative of abandoning SOGIECE. In recounting a time in which outside efforts to suppress her gender identity and expression had intensified, one participant described a corresponding intensification in her intent to kill herself:

I risked dying several times because I could not talk about my [true] gender identity. […] They [family members and faith-based SOGIECE practitioners] really wanted me to present myself to the world as a man, which I am not, at all! And that, that really was the realization that affected the most and that really hurt the most, knowing that I couldn’t affirm my identity, in any way, and that I just had to keep it locked inside of me. It was really, really hard. […] I felt so, like, being put back in a prison that I had just left, like, the only thing I was thinking about in that moment – at that time, the hall was, and is still near the river, so the river was the only thing I could see in front of me when I left – was that it would be better to die than to not able to live my life fully, without restrictions, and with the happiness that I deserved to have (30- to 39-year-old person who identifies as pansexual, trans, non-binary, genderfae, and a woman).

Discussion

This study with people with lived experience of SOGIECE identified that these practices create and/or exacerbate multiple adverse health and social impacts, including feelings of “brokenness,” social and relational consequences, and impaired mental health and wellbeing. Critically, our findings show that SOGIECE contribute to serious mental distress and illness, including diagnosed anxiety and depressive disorders, in addition to experiences of suicidality. These findings situate the continued occurrence of SOGIECE as both a product of, and contributor to, societal inequities facing 2SLGBTQ+ people.

In this study, participants frequently described the ways in which their sexual and gender identities had been rejected, pathologized and devalued by SOGIECE practitioners and through cisheterosexist and non-affirming messaging. Participants described how this “othering” had contributed to pronounced feelings of social isolation and lack of belonging, in addition to a series of other lasting impacts (e.g., challenges engaging in romantic relationships, lost opportunities in relation to education and employment). In considering these social and relational challenges, our findings align with existing research that underscores the need for family and community members to support and affirm 2SLGBTQ+ people, particularly in ways that foster positive personal and sexual and gender identities, rather than compounding experiences of minority stress marked by victimization, rejection, and internalized stigma (Green et al., 2020; Meyer, 2003; Caitlin Ryan et al., 2020). Further, because the parents and support persons (e.g., religious leaders, healthcare providers) of people with lived experience of SOGIECE are typically motivated by doing what they think is best for those in their care (C Ryan, 2009; Caitlin Ryan et al., 2020), targeted educational efforts are needed to assist families and broader communities in understanding the relationship between rejection/acceptance and health and wellbeing for 2SLGBTQ+ people. Alongside such efforts, however, is demand for concerted research and policy efforts to account for and address the structural determinants of inequities faced by 2SLGBTQ+ people, particularly as they permit and drive SOGIECE (e.g., laws related to the rights of 2SLGBTQ+ people; societal and religious discourses surrounding the acceptability of 2SLGBTQ+ “lifestyles”).

Findings from this study underscore the extent to which SOGIECE disrupt opportunities for 2SLGBTQ+ people to experience mental and social wellbeing. For example, participants in the current study offered rich descriptions of the ways in which SOGIECE had contributed to poor self-image and self-esteem. Moreover, participants described deep-seated feelings of guilt and shame related to their sexual and gender identities, in addition to their experiences with SOGIECE (e.g., due to: their perceived role in attending SOGIECE, feelings of “letting down” others by not suppressing their sexual and gender identities). These findings align with prior research wherein sexual orientation change efforts were overwhelmingly found to elicit feelings of shame, guilt, and self-hatred (Cramer et al., 2008; Flentje et al., 2014). In addition, findings of this nature contextualize anecdotal reports from our community and policy engagement efforts related to SOGIECE (Salway, 2020a), wherein community members have described a hesitancy to share their SOGIECE stories due to feelings of shame and concern that they may be judged by others. These findings have considerable implications for advocacy work, as they both underscore the need to meaningfully engage people with lived experience to share their stories in SOGIECE-related policy discussions, and, further, to scale-up and de-stigmatize everyday conversations and educational efforts related to SOGIECE and their impacts.

The adverse SOGIECE-related mental health impacts highlighted in this study are similar to those reported in the extant SOGIECE literature – namely, loneliness, substance use, depression, anxiety, and suicidality (Flentje et al., 2014; Green et al., 2020; Caitlin Ryan et al., 2020; Salway et al., 2020; Turban, Beckwith, et al., 2019). The current study adds to this predominantly quantitative literature by conveying the distinct and multiple pathways through which SOGIECE create this burden of mental distress. These pathways include an internalized sense of brokenness, disrupted or destroyed social supports and opportunities for personal growth, and a sense of failure or shame at having undertaken ineffective SOGIECE. Participants attributed a spectrum of mental health-related harms to SOGIECE – ranging from feelings of isolation and shame to more pronounced manifestations of mental distress (e.g., the development of anxiety, mood, and post-traumatic stress disorders). Of particular concern, many participants in our study also disclosed having become suicidal during and following their experiences with SOGIECE. A plausible association between SOGIECE and these adverse mental health outcomes can be conceptualized through the minority stress framework (Brooks, 1981; Meyer, 1995, 2003; Rich et al., 2020; Turban, Beckwith, et al., 2019), wherein stigma-related stress from exposure to SOGIECE and broader cisheterosexist influences are thought to increase emotional dysregulation, interpersonal dysfunction, and risk for mental health problems. Indeed, SOGIECE have been called “the sharpest edge of minority stress” (Salway, 2019).

To facilitate efforts to address the poor mental health experiences identified in this study and in previous research in this area (Salway et al., 2020), we urge all people with lived experience of SOGIECE to have discussions with their healthcare and peer supports regarding any lasting psychological sequelae related to SOGIECE. Concomitantly, we agree with elsewhere-documented appeals (Green et al., 2020; Meanley et al., 2019) for healthcare providers to proactively screen 2SLGBTQ+ clients for exposure to SOGIECE, and, if such exposure is present, to assess and support their mental health in a trauma-informed, non-judgmental, and person-centered manner. It is of paramount importance that healthcare providers be aware of and responsive to the mental health and societal inequities facing this priority population, if we are to meaningfully advance equity in health and healthcare access for 2SLGBTQ+ people in the context of SOGIECE and more generally. Further to these strategies, there is critical demand for upstream measures that prevent SOGIECE from occurring in the first place. We therefore join calls for the immediate design and implementation of comprehensive policy interventions (e.g., healthcare profession-specific regulatory measures; legislative efforts) to ban SOGIECE across Canada and the globe (Department of Justice Canada, 2020; Mallory et al., 2019; Salway, 2020b). The successful advancement of interventions such as these will also benefit from judicious research and evaluation efforts, including concerted investigation into what survivors of SOGIECE themselves deem to be the most needed and effective supports – insights that are presently lacking in the extant literature.

This study has strengths and limitations that should be noted. This study captured highly contextualized descriptions of the health and social impacts of SOGIECE from the standpoints of a pan-Canadian sample of people with lived experience. Yet, social desirability bias may have contributed to inaccurate or incomplete reporting of the stigma-laden topics under study (e.g., 2SLGBTQ+ identities, mental illness). Furthermore, while our stratified purposive sampling strategy had intended to recruit a diverse group of people with lived experience of SOGIECE, our study sample predominantly included cisgender gay men. Additional research is needed to explore how the experiences and impacts of SOGIECE vary within and across 2SLGBTQ+ populations, with particular attention to those who tend to be underrepresented in sexual and gender minority health research (e.g., queer women, trans people; queer and trans Black, Indigenous, and people of colour). Similarly, future research should explore how the diverse social positionalities of people with lived experience of SOGIECE (e.g., with respect to: age, ethnocultural identity, religiosity, culture, socioeconomic status) interact with various contexts and systems of oppression in ways that may shape experiences and trajectories of SOGIECE.

Conclusion

There is mounting evidence of the ineffectiveness of and harms caused by SOGIECE; however, these practices remain prevalent across Canada and the globe. Our study provides a highly contextualized investigation of the ways in which SOGIECE result in adverse health and social outcomes among people with firsthand experience of these practices. In particular, our findings underscore that SOGIECE contribute to interconnected, deleterious experiences of guilt, shame, social isolation, poor mental health, and suicidality. Taken as a whole, these findings identify SOGIECE as both a key consequence and driver of societal inequities facing 2SLGBTQ+ people in Canada. Equity-oriented interventions to end SOGIECE and support the health and wellbeing of those who have experienced it are needed at the individual, community, healthcare, and structural policy levels. Specifically, findings from this study underscore the need for comprehensive policy and legislation to prevent SOGIECE, enhanced sexuality- and gender-related educational efforts with the families and support persons (e.g., religious leaders, healthcare providers) of 2SLGBTQ+ people, and targeted mental health screening and supports for people with lived experience of SOGIECE. To more fulsomely realize the potential of these policy and programmatic recommendations, we concomitantly urge that people with lived experience be centered in all efforts to redress the far-reaching harms associated with SOGIECE.