Research and analysis

Conversion therapy: an evidence assessment and qualitative study

Published 29 October 2021

1. Executive summary

1.1 Background

The UK government has committed to exploring legislative and non-legislative options for ending so-called ‘conversion therapy’.

In this report the term ‘conversion therapy’ is used to refer to any efforts to change, modify or supress a person’s sexual orientation or gender identity regardless of whether it takes place in a healthcare, religious or other setting.

The aim of this research was to improve understanding of the practice and to address the following 4 questions:

1. What forms does conversion therapy take?
2. Who experiences conversion therapy and why?
3. What are the outcomes of conversion therapy?
4. What measures have been taken to end conversion therapy around the world?

To answer questions 1 to 3, we carried out a rapid evidence assessment of research published from January 2000 to June 2020. We identified 46 published studies. Most of the evidence was specifically focused on conversion therapy aimed at changing sexual orientation, with only 5 articles that specifically addressed conversion therapy to change gender identity.

We also carried out a qualitative study to gather evidence on the experiences of people in the UK who had undergone conversion therapy. We interviewed 30 people (16 men, 12 women, 2 non-binary) who had experienced either sexual orientation change efforts (24), gender identity change efforts (3) or both (3).

To answer question 4, we carried out a search of the grey literature to identify measures taken around the world to end conversion therapy.

1.2 Key findings

1. What forms does conversion therapy take?

Evidence suggests that modern forms of conversion therapy are commonly based on a belief that same-sex sexual orientations and transgender identities are developmental disorders, addictions or spiritual problems.

The most common methods we identified involved a combination of

• spiritual methods – for example, prayer ‘healing’ or exorcisms, and pastoral counselling
• psychological methods – for example, talking therapies

The boundaries between religious and psychological approaches are often unclear with many combining the 2 in a way that could be described as pseudo-scientific.

Conversion therapy appears to be most commonly carried out in religious settings by religious individuals or organisations, but it may also be done by mental health professionals or family members. In some cases, secular mental health professionals may treat minority gender identities (for example, non-binary) or minority sexual orientations (for example, asexual) as symptoms of existing mental health conditions. It is unclear how often this is a deliberate attempt at conversion therapy.

There is less evidence relating to gender identity change efforts but what evidence there is suggests that conversion therapy with transgender people can take a very similar form to that aimed at changing sexual orientation.

2. Who experiences conversion therapy and why?

There is no representative data on the number of lesbian, gay, bisexual and transgender (LGBT) people who have undergone conversion therapy in the UK. However, some evidence appears to suggest that transgender people may be more likely to be offered or receive conversion therapy than cisgender lesbian, gay or bisexual people.

There is consistent evidence that exposure to conversion therapy is associated with having certain conservative religious beliefs.

Common reasons given for seeking out conversion therapy are:

• a perceived incompatibility between someone’s religious values and their sexual orientation or gender identity
• a desire to belong and feel ‘normal’ within a community
• external pressure or coercion by someone’s family members or people from their faith community

Some people report that while they underwent conversion therapy voluntarily, they feel these ‘choices’ were shaped by powerful influences in their social environment and under guidance from authority figures.

3. What are the outcomes of conversion therapy?

There is no robust evidence to support claims that conversion therapy is effective at changing sexual orientation or gender identity.

Some of the largest studies report little to no reported change in sexual orientation, and reports of success are unpersuasive due to serious methodological limitations and sometimes major flaws in study designs.

No studies which examined the effectiveness of conversion therapy aimed at changing gender identity were identified during the search period (2000 to 2020).

Evidence of harm associated with conversion therapy outweighs reports of some benefits, such as social support and a sense of belonging. In addition, the reported benefits are common to most forms of talking therapy or support groups and could be provided by other, more affirmative, approaches that mitigate risks of harm.

There is an increasing amount of quantitative evidence that exposure to conversion therapy is statistically associated with poor mental health outcomes including suicidal thoughts and suicide attempts. This body of evidence is larger for sexual orientation change efforts. However, one recent study has also found that gender identity change efforts are associated with similar negative health outcomes.

Although we need to take care when making causal inferences, qualitative studies have found that people who have undergone conversion therapy attribute such feelings to the conversion therapy. The majority of people we interviewed in this study described experiencing conversion therapy as harmful, and reported self-harm and suicidal thoughts.

Plausible explanations for such harms include that conversion therapy makes internal conflicts worse rather than resolving them. It also reinforces the stigma associated with minority sexual orientations or gender identities.

4. What measures have been taken to end conversion therapy around the world?

Most countries’ interventions to combat conversion therapy appear to apply to both sexual orientation and gender identity change efforts. Some apply to sexual orientation change efforts only.

A range of legal and regulatory interventions have been introduced internationally to restrict conversion therapy. These vary in scope and have targeted a variety of sectors either individually or in combination (for example, healthcare contexts, religious contexts and advertising).

There have been several legal challenges to bans in the USA, but no judicial decision has overturned a ban on conversion therapy as yet.

A conversion therapy ban has been successfully applied to sanction a life coach offering conversion therapy in Madrid, which has one of the world’s most comprehensive laws on conversion therapy.

1.3 Conclusions

Modern forms of conversion therapy appear to largely take the form of talking therapies and spiritual interventions. There is evidence that these forms of conversion therapy can be harmful – but there is no robust evidence that identifies whether certain techniques or practices used by conversion therapists are more or less harmful than others.

The evidence base is larger for sexual orientation change efforts than for gender identity change efforts.

A growing number of legal jurisdictions are legislating to restrict conversion therapy. The scope of such laws varies and, because many legislative measures are relatively recent, there is little evidence on what are the most effective policies for ending conversion therapy.

1.4 Authors

• Adam Jowett
• Geraldine Brady
• Simon Goodman
• Claire Pillinger
• Louise Bradley

Coventry University
June 2021

1.5 Disclaimer

This research was commissioned by the Government Equalities Office (GEO). The findings and recommendations are those of the authors and do not represent the views of GEO or government policy. While GEO has made every effort to ensure the information in this document is accurate, they do not guarantee the accuracy, completeness or usefulness of that information.

2. Introduction

2.1 Policy context

The National LGBT Survey 2017 (GEO, 2018) found that:

• 2% of the 108,000 respondents had previously undergone conversion therapy in an attempt to ‘cure’ them of being LGBT
• a further 5% had been offered it

Transgender respondents were more likely to have reported having undergone or been offered conversion therapy (13%) than cisgender respondents (7%).

‘Transgender’ in this report describes people whose gender identity is different to their sex recorded at birth. ‘Cisgender’ refers to people whose gender identity matches their sex recorded at birth.

In addition to these findings, there is increasing evidence that attempts to change a person’s sexual orientation or gender identity can cause serious harm.

From an international perspective, a number of states – including Canada, Germany, Malta, Republic of Ireland, Australia and various US states – have either passed legislation or are bringing forward legislative and other measures to combat conversion therapy.

The UN Independent Expert on protection against violence and discrimination based on sexual orientation and gender identity has called for conversion therapy to be banned around the world (IESOGI, 2020).

In 2018, the government committed to exploring legislative and non-legislative options for ending conversion therapy in the UK. GEO commissioned this research to inform policy development on the legislative and non-legislative options for ending conversion therapy in the UK.

2.2 Background

‘Conversion therapy’ is commonly used as an umbrella term to refer to attempts to modify someone’s sexual orientation or gender identity.

It goes by many other names including:

• ‘reparative therapy’
• ‘sexual reorientation therapy’
• ‘ex-gay therapy’

The word ‘therapy’ may not accurately reflect the nature of conversion efforts which may take the form of religious practices rather than using ‘therapeutic’ approaches.

Within scientific literature, the terms ‘sexual orientation change efforts’ (SOCE) and ‘gender identity change efforts’ (GICE) are used to refer to all conversion efforts including medical, psychological and religious approaches. See Appendix 1 for a glossary of terms used in this report.

So-called ‘conversion therapy’ was originally conceived in the early to mid-20th century, at a time when homosexuality and ‘transsexualism’ (as it was called then) were considered mental disorders.

Conversion therapies were administered by mental health professionals, sometimes by court order (for example, Alan Turing). They included methods such as:

• aversive behavioural techniques – for example, electric shocks or chemically-induced nausea
• hormone therapy – for example, ‘chemical castration’
• hypnosis and psychotherapy (King and Bartlett, 1999)

Today, same-sex sexual orientations and transgender identities are considered a normal part of human variation and are not included as mental disorders within the latest edition of the WHO’s International Classification of Diseases.

Most evidence-based recommendations for working therapeutically with LGBT people in distress endorse psychological approaches that provide unconditional acceptance, identity exploration and social support to help them work through difficult emotions (American Psychological Association, 2009a, 2009b, 2012, 2015, British Psychological Society, 2019, and King and others, 2007).

Many UK psychotherapy, counselling and health professional bodies have signed a memorandum of understanding which sets out a joint position that conversion therapies are unethical and potentially harmful.^{[footnote 1]}

Over 60 health professional associations across more than 20 countries have adopted position statements against conversion therapies (ILGA World, 2020). Some religious institutions are starting to adopt similar positions. In 2017, the Church of England’s national assembly voted to endorse a memorandum against conversion therapy. A growing number of former leaders of ‘ex-gay’ organisations have also publicly rejected their effectiveness and warned about the harm produced by the methods they were involved in delivering (ILGA, 2020).

2.3 Aims of the report

The aim of this report is to improve understanding of the practice, experience and effect of conversion therapies. The research seeks to address the following 4 questions:

1. What forms does conversion therapy take?
2. Who experiences conversion therapy and why?
3. What are the outcomes of conversion therapy?
4. What measures have been taken to end conversion therapy around the world?

3. Method

To answer the research questions, we carried out:

• a rapid evidence assessment
• a qualitative study with people who had undergone conversion therapy in the UK

The approach is summarised in this chapter. See Appendix 2 for full details.

3.1 Rapid evidence assessment and review of international practice

A rapid evidence assessment was conducted based on guidance produced by the EPPI-Centre for Civil Service on Rapid Evidence Assessment (Civil Service, 2014). The search was limited to empirical papers published in academic journals by professional organisations or government bodies. They had to be available in English to answer the first 3 research questions.

The search was limited to papers published from 1 January 2000 to 30 June 2020. Search terms were based on those used in previous reviews of conversion therapy in consultation with a specialist subject librarian and agreed in advance with GEO.

Inclusion and exclusion criteria were applied, resulting in 46 articles and reports being included in the review. Most of the evidence focused specifically on sexual orientation change efforts, with only 5 articles specifically addressing gender identity change efforts. One report addressed them both. See Table 1 for a summary of article characteristics.

Table 1: Summary of article characteristics

Characteristic	Sexual orientation change efforts (SOCE): 40 articles	Gender identity change efforts (GICE): 5 articles	Both SOCE and GICE: 1 article
Geography	35 North America 2 South Africa 1 UK 1 Poland 1 China	4 North America 1 UK	1 UK
Design	19 Qualitative 19 Quantitative 2 Systematic reviews	1 Qualitative 3 Quantitative 1 Systematic review	1 Quantitative
Topic	6 Prevalence and characteristics of those who undergo SOCE 4 Associations between exposure to SOCE and harmful outcomes 6 Effectiveness at changing sexual orientation 2 Conversion therapists’ views and framing of SOCE 2 Quality assessments of evidence 1 Health professionals’ views on SOCE 18 Experiences of conversion therapy	1 Prevalence and characteristics of those who undergo GICE 1 Associations between exposure to GICE and harmful outcomes 1 Nature of conversion therapy practices 1 Conversion therapists’ views and framing of GICE 1 Perceptions of different therapy responses among transgender participants	1 Prevalence and characteristics of those who undergo conversion therapy
Quality	Overall tended to be of average quality. Effectiveness studies tended to be lower quality due to design limitations.	Overall tended to be above average quality	Average quality

We carried out an additional search of the grey literature to answer the fourth research question about measures taken around the world. This was because none of the studies from the academic literature could adequately answer this question or provide up-to-date information.

3.2 Qualitative interviews

For the qualitative study, we interviewed 30 people with experience of conversion therapy in the UK. Ethical approval was granted through Coventry University’s institutional ethics procedures before data collection. Interviews took place between April and July 2019. Interview questions were developed based on the study objectives and initial findings from the rapid evidence assessment, in consultation with GEO.

Participants were recruited via a range of methods including:

• social media
• contacting a range of stakeholder organisations (for example, LGBT, religious and healthcare)
• fliers at several Pride festivals

Potential participants had to register their interest in taking part through a screening survey. They were also given more information about the research and links to sources of support.

Participants were screened for eligibility. To be eligible, they must have had first-hand experience of conversion therapy in the UK within the last 20 years. Of the 30 interviewees:

• 20 had experienced conversion therapy within the last 10 years (including 2 who were undergoing it at the time they were interviewed)
• 10 had experienced conversion therapy between 10 and 20 years ago^{[footnote 2]}

28 interviewees lived in England, 1 in Scotland and 1 in Northern Ireland. Most interviewees lived in urban areas (26). The sample was predominantly White (28) and Christian (22), despite attempts to reach out to people from ethnic minority backgrounds and from other faith groups. See Table 2 for a summary of sample characteristics.

Table 2: Summary of interviewee characteristics

Sample characteristics
Age	20 to 60 years (average 39 years)
Gender	16 men 12 women 2 non-binary people
Gender identity	24 cisgender 6 transgender/non-binary
Sexual orientation	19 lesbian or gay 2 bisexual 3 heterosexual 1 pansexual 4 asexual 1 other (‘same-sex attracted’)
Ethnicity	28 White 1 Black 1 Mixed/multiple ethnic group
Religion	22 Christian 5 no religion 2 agnostic 1 Gaian
Aim of conversion therapy	24 sexual orientation change efforts 3 gender identity change efforts 3 both

All interviewees were provided with relevant information and signposted to helplines and sources of professional support.

3.3 Limitations

The inclusion criteria for the rapid evidence assessment was limited to research published in academic journals, by professional bodies and government departments. See Appendix 2 for full inclusion criteria. Grey literature not captured in the rapid evidence assessment may provide important sources of evidence regarding the forms that conversion therapy takes in the UK. These include:

• undercover journalistic investigations (for example, Brand, 2018, and Strudwick, 2011)
• surveys published by charities and other organisations (for example, Bachmann and Gooch, 2018, and Ozanne Foundation, 2019)

No randomised control trials have been conducted in relation to the effectiveness or harmfulness of conversion therapy. The studies included in the rapid evidence assessment therefore fall short of the ‘gold standard’ in clinical evidence for assessing effectiveness. This is mainly due to the following methodological limitations:

• a lack of prospective, controlled study designs that can robustly examine causal relationships
• a reliance on retrospective self-reporting
• a reliance on self-selected and potentially biased samples
• a lack of longitudinal studies that follow individuals over time
• the use of different (and often unreliable) measures of ‘success’
• the inclusion of a wide variety of conversion therapy approaches

See Appendix 2 for an overview of each.

It should be noted that it would be practically and ethically difficult to conduct randomised control trials on forms of conversion therapy. It is therefore unlikely that there will ever be ‘gold standard’ evidence upon which to base policy and this report is based on the best available evidence.

There is relatively little published evidence available regarding gender identity change efforts and only a small number of those interviewed for this study had undergone gender identity change efforts.

As people who have undergone conversion therapy are a hidden population, the interview study necessarily relied on a self-selecting sample. Our recruitment strategies may have introduced sampling biases, and this is unavoidable. It is also based on a relatively small sample. It is not possible to determine how representative the findings are to the wider population of those who have undergone conversion therapy. In addition to the limited number of transgender participants, a lack of ethnic minority interviewees also limits the generalisations we can make from these findings.

The qualitative findings are based on retrospective self-reporting. Such accounts may not always be entirely accurate due to needing to rely on people’s memory. It is possible that the providers of the conversion therapy may recall a different version of events. In 10 cases, their experience of conversion therapy was 10 to 20 years ago, so their memory of these episodes may become distorted over time, or their experiences may not represent current practices.

Quotes from interviewees have been used in this report to illustrate main findings and to give specific examples of the people’s experiences. Quotes have been labelled to show:

• the interviewee’s sex registered at birth and self-reported gender (for example, cisgender man, transgender woman)
• their self-reported sexual orientation (for example, lesbian, gay, bisexual)
• their age range (for example, 20s, 30s)
• whether they had undergone sexual orientation change efforts (SOCE) or gender identity change efforts (GICE)

4. What forms does conversion therapy take?

This chapter outlines:

• common beliefs among people and organisations who provide conversion therapy
• the frameworks and techniques used
• different settings and providers of conversion therapy

Findings from the published literature are shown, followed by evidence from interviews conducted for this report.

4.1 Overview

Conversion therapists typically see same-sex sexual orientations and transgender identities as:

• spiritual problems – for example, caused by sin or demonic forces
• developmental disorders – for example, caused by childhood trauma

Conversion therapy methods are often:

• spiritual techniques – for example, prayer or exorcism, pastoral counselling
• psychological techniques – for example, talking or behavioural therapies
• pseudo-scientific forms of religious counselling that combine spiritual and psychological techniques

Conversion therapy occurs in a range of settings, typically by religious people or organisations.

There is evidence that in mental health settings there are some potentially rare cases of minority sexual orientations (asexual) and gender identities (transgender and non-binary) being misinterpreted as symptoms of a mental disorder.

Qualitative evidence gathered for this report suggests conversion therapy in similar in the UK and USA.

4.2 What conversion therapists believe

Findings from rapid evidence assessment

This section is based on a diverse body of evidence including:

• a survey of conversion therapists (Nicolosi, Byrd and Potts, 2000a)
• studies analysing reparative therapy websites and materials (Arthur, McGill and Essary, 2013, Mikulak, 2020, and Robinson and Spivey, 2019)
• qualitative studies with people who have undergone conversion therapy (Beckstead, 2002, Beckstead and Morrow, 2004, Fjelstrom, 2013, Flentje, Heck and Cochran, 2013, Flentje, Heck and Cochran, 2014, Johnston and Jenkins, 2006, Mikulak, 2020, Schroeder and Shidlo, 2002, Shidlo and Schroeder, 2002, Van Zyl, Nel and Govender, 2017, Van Zyl, Nel and Govender, 2018)

Most of this research originates from North America and may not reflect how conversion therapy operates in all parts of the world today.

All forms of conversion therapy have the aim of ‘helping’ people attempt to resist, minimise or change their same-sex or transgender behaviours, thoughts or feelings (Nicolosi, Byrd and Potts, 2000a).

Relatively little research has been conducted directly on the beliefs of conversion therapists, although this can be gathered to some degree from literature published by conversion therapists themselves and reports from those who have undergone conversion therapy.

Common themes that run through this literature are that many conversion therapists believe that being LGBT is a mental disorder and can be altered or ‘healed’. Many also have religious beliefs that God intends for everyone to be heterosexual and cisgender.^{[footnote 3]}

One US-based survey of 206 conversion therapists, conducted by prominent conversion therapy advocates, found that:

• 97% of conversion therapists ‘strongly’ or ‘mostly’ agreed that a homosexual client may be capable of change to a heterosexual orientation
• 93% ‘strongly’ or ‘mostly’ agreed that homosexuality was a developmental disorder
• 90% ‘strongly’ or ‘mostly’ agreed that the American Psychiatric Association’s decision to declassify homosexuality as a mental disorder in 1973 was politically motivated
• 63% believed it could be helpful to bring prayer into the therapeutic setting (Nicolosi, Byrd and Potts, 2000a)

The authors noted that many of the conversion therapists also viewed same-sex sexual behaviour as ‘an addiction’. Although this was based on a self-selected sample and published in 2000, these findings match what we know from literature written by influential conversion therapists, including one of the study’s authors.^{[footnote 4]}

These findings are also consistent with published qualitative evidence in which people who have undergone conversion therapy report being told by therapists that homosexuality is a developmental disorder, a symptom of sexual addiction or otherwise intrinsically disordered (for example, Fjelstrom, 2013, Schroeder and Shidlo, 2002).

The survey by Nicolosi, Bryd and Potts (2000a) also found that 82% of conversion therapists strongly or mostly agreed that homosexuality is a ‘gender identity problem’. This is consistent with studies examining gender identity change efforts which find that many conversion therapists routinely combine issues of sexual orientation and gender identity, viewing them as results of ‘gender identification deficits’ and drawing on similar causal theories (Robinson and Spivey, 2019, Wright, Candy and King, 2018).^{[footnote 5]}

As with same-sex sexual orientations, conversion therapists tend to view transgender identities as arising from impaired development, deficient caregiver role models or childhood trauma (Wright, Candy and King, 2018).

Findings from qualitative research

These general beliefs were also reported in our qualitative research interviews. Interviewees commonly reported that their conversion therapists believed that their sexual orientation or gender identity was a problem of childhood development or trauma.

Interviewees reported that the person performing the conversion efforts used the term ‘brokenness’ to describe their sexual orientation or gender identity. The term ‘healing’ was often used when referring to changing their sexual orientation or gender identity.

They also said conversion therapists attributed feelings of unhappiness to a ‘homosexual lifestyle’ rather than as a result of their internal conflict and internalised stigma. Interviewees reported that changing their sexual orientation or gender identity was not always explicitly the aim – the focus was sometimes more on modifying sexual behaviour – but that the person providing the conversion therapy believed change was a possibility.

Some interviewees who experienced conversion therapy in religious settings also said that providers attributed same-sex sexual orientations to demonic forces or sins of previous generations. And in some cases, religious providers would draw on a combination of pseudo-psychological and spiritual explanations.

[According to those providing conversion therapy] it was all because I had a poor relationship with my dad, and there was no affection in the relationship with my father, that was the constant theme that went through both the organisations that I was working with. And again that was linked to the relationship with my father, that allowed the demons to take hold.

(Cisgender man, gay, 50s, sexual orientation change efforts)

4.3 Frameworks and techniques involved

Findings from rapid evidence assessment

To identify conversion therapy techniques, we drew on a diverse range of studies including:

• a survey of conversion therapists (Nicolosi, Byrd and Potts, 2000a)
• qualitative studies (for example, Fjelstrom, 2013, Flentje, Heck and Cochran, 2013, Johnston and Jenkins, 2006, Mikulak, 2020, Schroeder and Shidlo, 2002, Throckmorton and Welton, 2005, Van Zyl, Nel and Govender, 2017)
• surveys with people who had undergone conversion therapy (for example, Dehlin and others, 2015)
• a wide ranging systematic review (APA, 2009a)

The techniques these studies identified can be categorised as falling within either a ‘spiritual’, ‘psychoanalytic’ or ‘cognitive-behavioural’ framework.^{[footnote 6]}

Overview of conversion therapy frameworks

Religious or spiritual framework:

• Premise: Same-sex attractions and transgender identities are caused by evil spiritual forces, sins of previous generations or are a test from God. Same-sex sexual behaviour or cross-dressing are sinful or immoral.
• Techniques include: Prayer ‘healing’ (including exorcising spirits), confession and repentance, faith declarations, fasting, pilgrimages, Bible reading, attending religious courses.
• Setting: Within a religious community, in places of worship, at religious conferences and festivals, on religious conversion therapy courses.
• Provider: A religious leader (for example, vicar or priest, youth pastor), other members of the church or faith community, a religious therapist.

Psychoanalytic framework:

• Premise: Same-sex attractions and transgender identities are developmental disorders resulting from a variety of familial (for example, distant relationship with a parent), social (for example, rejection by childhood same-sex peers) or traumatic (for example, childhood sexual abuse) factors.
• Techniques include: Exploring ‘causes’ through a discussion of childhood trauma, psychodrama, emotional-release work, ‘father-son style holding’, altering gender-role behaviour.
• Setting: One-to-one or group therapy or pastoral counselling, conversion therapy weekend retreats or courses.
• Provider: A group or organisation (often religious), therapist, life coach or pastoral counsellor (with or without any formal training).

Cognitive-behavioural framework:

• Premise: Same-sex attractions and transgender identities are a behavioural problem similar to an addiction or compulsive behaviour.
• Techniques include: Reframing desires, redirecting thoughts, avoiding ‘triggers’, abstaining from masturbation or masturbatory reconditioning, journaling, accountability buddies/groups, behaviour modelling, covert aversive methods (for example, snapping a rubber band on the wrist).
• Setting: One-to-one or group therapy or pastoral counselling, weekend retreats or courses, AA-style mutual aid groups (sometimes alongside people who suffer from addictions and/or sexual problems).
• Provider: A therapist, life coach or pastoral counsellor (with or without any formal training) and/or a group or organisation.

We refer to these as ‘frameworks’ because different techniques are based on certain sets of assumptions about human behaviour and the causes of sexual orientation or gender identity. However, these do not represent 3 different ‘types’ of conversion therapy as a combination of these are often found within a single form of conversion therapy (for example, religious and psychoanalytic ideas).^{[footnote 7]}

Psychological frameworks (psychoanalytic and cognitive behavioural) are based on historic efforts to alter sexual orientation and gender identity through psychoanalytic and behaviour therapy (Drescher, 1998). These ‘psychological’ theories in relation to sexual orientation and gender identity have been rejected by numerous professional associations including the British Psychological Society (BPS), the British Psychoanalytic Council (BPC) and British Association of Behavioural and Cognitive Psychotherapies (BABCP).^{[footnote 8]} Conversion therapies are often only loosely based on these psychological theories in ways that could be described as pseudo-scientific.

There is very limited evidence about the methods used to change gender identity. A systematic review by Wright, Candy and King (2018) found only 4 relevant studies. The study concluded that treatment for modifying gender identity and changing sexual orientation appeared to be similar, and that they both adopted psychoanalytic and behavioural techniques. There is also evidence that some forms of gender identity change efforts are based in the same religious frameworks as sexual orientation change efforts (Robinson and Spivey, 2019).^{[footnote 9]}

Findings from qualitative research

Although most of the available evidence is from North America, the qualitative data gathered from our interviews in the UK largely support these findings.

Spiritual or religious techniques:

Many interviewees had undergone different types of conversion therapy (sometimes over a period of years). There were no notable differences in the techniques used in the last 10 years compared with 10 to 20 years ago. Most people reported experiences of being offered prayer healing or exorcisms (called ‘deliverance ministry’) which sometimes involved laying hands on the body and shouting at the person believed to be possessed.

I think probably more than once I was delivered of a spirit, or a demon of homosexuality. And then I was told that if I did anything sinful based on the fact that I’d been delivered from these demons, that those demons would return, and they would bring 7 other demons with them.

(Cisgender man, gay, 40s, sexual orientiation change efforts)

Some interviewees said they were encouraged to engage in confession and repentance in front of others. They had to repeat statements of faith such as “I’m not a lesbian, I’m created by God to be in a relationship and one day I will have a husband”.

They said ‘right you have to do repentance’ so they said think of any thought you have had about the same sex that is sinful or ungodly and declare it in front of these people and talk about any kissing or sexual activity or anything you’ve done with the same sex. So obviously it was quite embarrassing.

(Cisgender woman, lesbian, 30s, sexual orientiation change efforts)

Forms of religious counselling sometimes referred to as pastoral guidance often involved faith-based discussions but were based loosely on psychoanalytic ideas and techniques. Religious counselling was also often delivered in conjunction with other activities such as religious support groups, workshops or conferences.

Many interviewees said they were encouraged to read ex-gay literature that one interviewee described as “Christian anti-gay books mostly from America”. No major differences were found between transgender and cisgender interviewees’ experiences of religious techniques. One transgender interviewee said they were given ex-gay literature on homosexuality by a priest and was told that it equally applied to issues of gender identity.

Other religious techniques referred to included studying the bible, fasting and spiritual pilgrimages. In one case, tithing (the practice of donating one-tenth of your earnings to the church) was proposed as a possible solution to unwanted same-sex attraction, including retrospectively tithing based on previous earnings.

Psychoanalytic techniques:

Interviewees commonly referred to psychoanalytic techniques such as looking for ‘causes’ by discussing childhood trauma and family relationships. They said therapists made suggestions as to the cause of their sexual orientation or gender identity.^{[footnote 10]}

We started talking about my family history. The counsellor convinced me that because my mum left and my dad would spend more time with my 2 sisters… that I was looking for the attention my sisters had and that was the feelings for my gender identity, so they kept pushing that into my head.

(Transgender woman, pansexual, 20s, sexual orientation change efforts and gender identity change efforts)

In another case, a cisgender gay man was told that he must have repressed the memory of being abused by his father. Several interviewees said that other techniques were forms of psychodrama in which they were encouraged to act out traumatic events from their past in order to release repressed emotions.

They would then get the person to get a baseball bat and hit a box and get the anger that they repressed at the time out and then the idea was that same sex attraction would shift because of this anger that had been repressed and stored. That was the basic premise of a lot of their exercises.

(Cisgender man, gay, 30s, sexual orientation change efforts)

Another technique reported – only by cisgender men in this sample – was ‘healthy touch’, also referred to as ‘safe healing touch’ or ‘father-son style holding’. Men were encouraged to hug and touch one another. Although only loosely based on psychoanalytic ideas, the premise was that such touch supposedly fulfils unmet needs from childhood and helps men to bond in non-erotic ways. One interviewee described an incident of sexual assault by a conversion therapist during ‘father-son style holding’. Cisgender men were also encouraged to engage in gender stereotypical activities including participating in ‘male-initiation rite of passage’ adventure weekends.

Cognitive behavioural techniques:

There is a common belief among conversion therapists that same-sex sexual behaviour is a form of addiction. In line with this belief, some interviewees took part in therapies based on models of addiction recovery which involved Alcoholics Anonymous-style support or ‘accountability’ groups. They were encouraged to identify behavioural triggers and given guidance on setting boundaries and how to avoid temptation. In some cases, this focused on particular techniques for avoiding masturbation or viewing (gay) pornography.

The guy that I’d work with would encourage me to resist watching pornography… it might be things like don’t have a computer in your room, or noticing when you first feel tempted to go and look at porn and see what’s going on, see if there’s a trigger.

(Cisgender man, heterosexual, 30s, sexual orientation change efforts)

Such techniques were used in combination with reframing thoughts and feelings, for example by encouraging people to view sexual attractions as something else (for example, loneliness) or advising them to keep busy as a form of distraction. Interviewees were also encouraged to socialise with heterosexual role models.

Aversive techniques were not reported by interviewees. However, one transgender interviewee reported that a priest tried to instil fear by showing them a graphic video of gender reassignment surgery.

4.4 Settings and providers

Findings from rapid evidence assessment

Findings from several published surveys suggest that conversion therapy tends to be delivered by religious providers (for example, Blosnich and others, 2020, Dehlin and others, 2015, Flentje, Heck and Cochran, 2013).

One study using random sampling found that over 80% of people who had experienced sexual orientation change efforts had conversion therapy from a religious provider (for example, a priest, pastor or religious counsellor). 31% had it from a healthcare provider (Blosnich and others, 2020).

Studies also suggest that people who go through conversion therapy often have more than one provider (for example, APA, 2009a, Dehlin and others, 2015). However, these studies were based in the USA.

As the settings and providers of conversion therapy may vary cross-culturally, this section is based mainly on evidence from:

• the 2017 National LGBT Survey (GEO, 2018)
• a UK survey of mental health professionals (Bartlett, Smith and King, 2009)

The National LGBT Survey found that, out of respondents who said they had received conversion therapy, faith organisations were by far the most likely group to have run the therapy (51%), followed by healthcare professionals (19%).

Table 3: Who conducted the so-called conversion therapy among respondents who reported experiencing it in the National LGBT Survey^{[footnote 11]}

Provider of conversion therapy	Percentage of respondents
Faith organisation or group	51%
Healthcare provider or medical professional	19%
Parent	16%
Any other individual or organisation not listed above	14%
Person from my community	9%

Source: GEO (2018)

Transgender respondents were slightly less likely to have undergone conversion therapy by faith organisations or groups (45%) than cisgender respondents (53%). People who filled in the optional free-text question on conversion therapy (n=230) often did so in the context of religion.

Although the National LGBT Survey was the largest of its kind – with 107,850 respondents – it was a self-selected sample and is not representative of all LGBT people in the UK. All respondents identified themselves as LGBT and may be different from – or have different experiences to – people who do not want to disclose their LGBT status, or people who no longer identify as LGBT. In addition, the survey did not ask how long ago the conversion therapy took place.

The fact that healthcare providers or medical professionals were the second most commonly-reported providers of conversion therapy suggests there are still some healthcare professionals providing it. It is not clear how widespread this is. It is also possible that some healthcare professionals deliver conversion therapy while working or volunteering for religious organisations rather than in healthcare settings.^{[footnote 12]} A much higher percentage of transgender respondents (29%) than cisgender respondents (15%) said their therapy had been conducted by healthcare professionals.

According to a 2002 UK-based survey of a random sample of members of UK psychotherapy and psychiatric organisations (n=1328), only 4% of therapists said they would attempt to change a client’s sexual orientation if asked (Bartlett, Smith and King, 2009). A higher percentage (17%) said they had helped at least one client to reduce or change homosexual feelings in the past, but this included historic cases.

The strengths of this study include its random sample and a high response rate. However, it is possible that professionals who conduct conversion therapy might not have responded, or they might not be members of the organisations surveyed. The figures could therefore be an underestimate.

The survey was carried out in 2002 before these professional bodies had adopted a memorandum of understanding on conversion therapy. For that reason, it might not accurately represent the percentage of their members who would conduct conversion therapy today.^{[footnote 13]}

In summary, the evidence suggests that conversion therapy most commonly takes place in religious settings. There is also evidence that some healthcare professionals may be providing conversion therapy – however, it is not known how widespread this is, and there is ambiguity around the settings in which healthcare professionals deliver it. A further issue is that some of the findings are based on older evidence and therefore may not be reflective of current practice.

Findings from qualitative research

The findings from the rapid evidence assessment were also reflected in the experiences we captured in our interviews with people who had undergone conversion therapy.

People from their faith community:

The majority of interviewees described experiences of people from their faith community attempting to change their sexual orientation or gender identity. Such attempts were commonly ad hoc and informal. What began as pastoral guidance would sometimes gradually and subtly progress to conversion attempts. The line between the 2 was often blurred.

The person delivering the ‘conversion therapy’ was often someone in a position of spiritual authority, such as a vicar, priest or youth pastor. They provided the therapy after the interviewee confided in them and sought guidance. These were often people from their local church community, and sometimes people they met at religious conferences or festivals.

Several interviewees were recommended conversion therapy by leaders at church youth groups or at university Christian Unions. These authority figures sometimes broke confidentiality by sharing private information with others in their faith community. They commonly signposted interviewees to religious people, groups or organisations for more formal attempts at change.

I got very involved in the youth group at that church, which I loved and I still have very positive feelings and memories of, but also that was where I had, I guess, some experience of what we’re talking about today. It was when I was 18, I told a friend who was also in this youth group and then the second person I told was the youth pastor at the church…Then we just started speaking more and more often… we spoke about things to do with my parents, that classic relationship with parents, perhaps that’s why.

(Cisgender woman, lesbian, 20s, sexual orientation change efforts)

Faith organisation or group:

Many interviewees had experienced more than one type of conversion therapy, and the majority had undergone conversion therapy by a religious group or organisation. These organisations (including registered charities) commonly described themselves as ‘pastoral support or counselling’ organisations (or ‘ministries’) for people with unwanted same-sex attractions or gender confusion. Some of these organisations had links with US-based conversion therapy groups,^{[footnote 14]} and some operated all over the UK.

Conversion therapy typically took the form of one-to-one or group pastoral support sessions that mixed spiritual, psychoanalytic and cognitive behavioural techniques. In some cases, the people delivering the support were not trained in counselling or psychotherapy and described what they were delivering as ‘talking ministry’ or ‘pastoral counselling’ rather than ‘therapy’.

Other interviewees reported that the group they attended was run by a mix of professionally trained and lay facilitators. In some cases, interviewees believed that trained mental health professionals worked or volunteered for the religious organisation, applying their professional skills and knowledge to conversion efforts.

Some of the guys would have been counsellors, some of them would have been therapists, accredited therapists and then they would often use quite a number of volunteers. So yeah, a real mixture of people.

(Cisgender man, gay, 40s, sexual orientation change efforts)

Some interviewees had themselves volunteered as peer facilitators and one had formerly held a leadership position within one of these organisations. Some attended religious (‘discipleship’) courses that aimed to improve participants’ spiritual lives or were specifically focused on ‘healthy relationships’. These were either short residential courses or run within church groups.

Although efforts to change sexual orientation or gender identity were not always the main purpose of such courses, some had specific sessions relating to sexuality and relationships or had pre-prepared prayers and literature for those with same-sex attractions. Several interviewees reported experiencing exorcisms (‘deliverance ministry’) during these courses.

I did a course there for a year which was a discipleship course, and during that time a lot of stuff was involved in healing yourself, and your mental processes and so on. And as part of that I felt like I needed to heal being gay. That happened over a process of a year or so, and as part of that there was quite an extreme exorcism-like situation.

(Cisgender man, gay, 30s, SOCE)

A number of cisgender men reported attending weekend retreats or conferences by inter-faith organisations that cater for men with unwanted same-sex attractions. These were advertised as being for people of all faiths, and religious doctrine or spiritual practices did not feature as strongly in the techniques used by these organisations. But they were described as being run by ‘men of faith’.

There was nothing faith-based, because it was all-faith and indeed none I suppose. It was aimed at people who had a strong faith, whatever that strong faith looked like. Because it was all encompassing there was nothing really that was relating to a faith, apart from I suppose a little like Alcoholics Anonymous.

(Cisgender man, ‘same-sex attracted’, 40s, sexual orientation change efforts)

These events typically had links with US-based ex-gay organisations. Some of the weekend retreats were versions of US conversion therapy retreats. For example, several male interviewees had attended weekend retreats in the UK delivered by a US-based ex-gay organisation. Several also reported travelling abroad to attend weekend retreats. Several reported having to sign non-disclosure agreements at the beginning of weekend retreats. Retreats involved lectures, psychodrama, ‘healthy touch’ and other group-based activities.

Interviewees said they either found out about these organisations online, were signposted to them by someone or learnt about them during some other form of conversion therapy. Several interviewees had attended various weekends run by more than one organisation.

Healthcare provider or medical professional:

A number of interviewees said their conversion therapy was provided by private psychotherapists and life coaches. In most cases, these providers were described as being religious.

I then went to meet someone who was a Christian counsellor who specialised in people who had got sexual struggles. It could have been someone who was struggling with pornography, or it could have been someone who was struggling with infidelity outside their marriage. So, it was quite broad, but they were someone who was a Christian counsellor or therapist.

(Cisgender man, ‘same-sex attracted’, 40s, sexual orientation change efforts)

One interviewee said they had video consultations with a US-based clinical psychologist known for practising reparative therapy. Another interviewee said they travelled to the USA to have a consultation with a psychotherapist. In one case, an interviewee reported being offered conversion therapy by a counsellor – who happened to be Christian – while having counselling for depression.

Several transgender, non-binary and asexual interviewees described be given what they thought was a type of conversion therapy by psychiatrists during inpatient and outpatient care while receiving treatment for a mental health condition (for example, schizophrenia). The treatment did not appear to be specifically designed to change their sexual orientation or gender identity. But one of its goals was getting them back to what the clinicians thought was ‘a normal life’, including aspects of their lives relating to their gender and sexuality.

The medical field, especially psychiatrists, wanted to believe it was a sign of mental illness. They figured, regardless of the fact that I was content with being asexual, that it was pathological, and that they could use that as a basis for my health. They took the fact my sexuality wasn’t changing as an indicator that the medicine wasn’t working, ignoring the fact the medicine was helping my other, actually distressing symptoms.

(Non-binary person, asexual, 20s, sexual orientation change efforts)

Clinicians were described as encouraging and rewarding behaviours that conformed to their expectations around gender and sexuality – such as wearing clothes associated with their sex or expressing interest in a member of the opposite sex – and using medication to alter their lack of sexual interest.^{[footnote 15]} Whether or not these experiences constitute ‘conversion therapy’ may depend on the definition, but they were perceived to be so by the interviewees.

Family members:

Although the efforts of parents at sexual orientation or gender identity change are included in the literature (for example, Ryan and others, 2018), there was little reference to this in our interviews. 3 interviewees said a parent or grandparent asked that a health professional or religious leader help change them. One of these also reported a parent putting pressure on them to have sex with people of the opposite sex.

She encouraged me into sexual relations with a man around my own age and told me it was ‘normal’ to not want to.

(Cisgender woman, asexual, 20s, sexual orientation change efforts)

The findings from the qualitative research are consistent with findings from the existing literature. They suggest that providers of conversion therapy include people within faith communities, religious and inter-faith organisations, healthcare providers and family members.

5. Who undergoes conversion therapy and why?

This section outlines the evidence on:

• how common conversion therapy is
• which groups within the LGBT population are more likely to be targeted
• the reasons why people have it

Evidence from the rapid evidence assessment is examined to consider how common conversion therapy is, and which groups are the most likely to be targeted.

Evidence from the rapid evidence assessment and the qualitative research is used to identify factors that lead to people having conversion therapy.

5.1 Overview

No robust data exists on the number of LGBT people who have had conversion therapy and which sections of the UK population are most likely to have it or be offered it.

Available evidence suggests those with conservative religious beliefs are most likely to have conversion therapy.

Studies with people who have undergone conversion therapy (mainly from the USA) are predominantly White Christian samples.

However, the National LGBT Survey 2017 found that respondents from ethnic minority groups and those with non-Christian faiths were more likely to report having had conversion therapy. (Note that the survey’s sample was not representative of the whole LGBT population.)

Evidence suggests that the main reasons for seeking conversion therapy include:

• a perceived conflict between someone’s religious values and their sexual orientation or gender identity
• a desire to be what is considered within their community as ‘normal’
• people feeling pressured to change by family members, people within their religious community or other pressures originating from their social environment

5.2 How common is conversion therapy?

Findings from rapid evidence assessment

There is little representative evidence on the prevalence of conversion therapy due to the hidden nature of the population and a reliance on self-selected samples. This section uses evidence from surveys of LGBT people in several countries including the UK.

In the 2017 UK National LGBT Survey, 2% of the 107,850 respondents said they had undergone conversion therapy. Another 5% said they had been offered it, and 1% were not sure (GEO, 2018). Amongst cisgender respondents, there was not much variation in who had undergone or been offered conversion therapy by sexual orientation. Bisexual respondents were the least likely to have undergone or been offered it (5%), and asexual respondents the most likely (10%).^{[footnote 16]}

These findings can be compared with recently-published results from surveys from outside the UK.

According to a Canadian survey of sexual minority men carried out in 2011 to 2012 (n= 8,388), 3.5% of respondents said they had been exposed to sexual orientation change efforts (Salway and others, 2020).

In a survey of LGB people in China (n=15,611), 6% of respondents said conversion therapy was recommended or provided to them in a health setting (Suen and Chan, 2020).

Both of these surveys were also self-selected samples.

2 studies from the USA reported the percentage of sexual minority men who had undergone sexual orientation change efforts as:

• 15% of 1,156 respondents (Meanley and others, 2020)
• 7% of 1,518 respondents (Blosnich and others, 2020)

A strength of the study by Blosnich and others was that it used a probability-based sample, through random digit dialling of USA landline and mobile phone numbers. As a result, its sample was more representative of the USA population as a whole.

In the UK, the National LGBT Survey 2017 found that transgender respondents were more likely to have undergone or been offered conversion therapy (13%) than cisgender respondents (7%) (GEO 2018).^{[footnote 17]}

However, in addition to the survey not being a representative sample, it did not distinguish between transgender respondents who had conversion therapy to change their sexual orientation and respondents who had it to change their gender identity.

By comparison, a 2017 US Transgender Survey found 14% of the 27,716 transgender respondents had been exposed to gender identity change efforts. 5% said this had happened between 2010 and 2015 (Turban and others, 2019).^{[footnote 18]} Although this was a large study, it was a self-selected sample as with many other surveys.

It is important to bear in mind that the prevalence of conversion therapy might be different in different countries. However, the evidence suggests that a minority of LGBT people experience conversion therapy and that transgender people may be more likely to have it or be offered it.

5.3 Which groups are most likely to undergo or be offered conversion therapy?

Findings from rapid evidence assessment

There is little research that directly examines the characteristics of people who have had conversion therapy. As a result, this section focuses mainly on a systematic review that looked at demographics (APA, 2009a) and data from the 2017 UK National LGBT Survey.

A previous systematic review showed that most participants in studies on sexual orientation change efforts were White men and from conservative Christian denominations (APA, 2009a). There is also some limited research with the Jewish community (Borowich, 2008). This pattern is also the case in research published more recently. The 2017 UK National LGBT Survey (GEO, 2018) suggests those who have conversion therapy are more likely to be religious, men, and from ethnic minorities.

Religion:

A previous systematic review of evidence on sexual orientation change efforts concluded that they appear to be aimed mainly at people with conservative religious beliefs (APA, 2009a). This may vary according to religious denomination, how questioning someone is of their religion, and the extent to which they internalise negative messages from their religion about their sexual orientation or gender identity (Tozer and Hayes, 2004).

Studies have found that religious fundamentalism or strong religious beliefs significantly predict participation in conversion therapy (Maccio, 2010, Dehlin and others, 2015). However, most of the evidence comes from North America and there is a general lack of representation of people from non-Judeo-Christian religions.

The National LGBT Survey 2017 (GEO, 2018) found differences based on religion or belief. Muslim respondents were the most likely to have had or been offered conversion therapy (27%), followed by Jewish (16%), Hindu (16%) and Sikh (15%) respondents. Respondents without a religion or belief were the least likely (7%).

This data should be treated with caution because respondents’ religious belief or identification might have changed as a result of negative experiences of religious-based conversion therapy. Some respondents might have identified with a religion at the time they underwent conversion therapy but identified as having ‘no religion’ at the time of the survey. Others might answer questions about religion on the basis of cultural heritage and identity rather than religious belief.

Ethnicity:

Most studies of people who have had conversion therapy (mostly from North America) have had mainly White respondents. In the UK, the National LGBT Survey 2017 found that respondents from Black (17%), Asian (16%) and Other ethnic groups (18%) were more likely than White (7%) respondents to have had or been offered it. This was similar among both transgender and cisgender respondents (GEO, 2018). A Canada survey of sexual minority men also found that people from ethnic minorities were more likely to report having experienced sexual orientation change efforts (Salway and others, 2020).

Gender:

The National LGBT Survey 2017 found that 8% of men said they had undergone or been offered conversion therapy, compared with 6% of women (GEO, 2018). Although this is a small difference, this pattern is consistent with studies on conversion therapy whose respondents have mostly been men (APA, 2009a).

Age:

The National LGBT Survey 2017 found little variation in the age of people who had undergone or been offered conversion therapy. This suggests that the issue has not only affected older generations historically (GEO, 2018).

5.4 Why do people have conversion therapy?

Findings from rapid evidence assessment

Much of the evidence about why people have conversion therapy comes from qualitative research, although information about motivations is also gathered in a small number of surveys (APA, 2009a, Flentje, Heck and Cochran, 2014, Karten and Wade, 2010, Maccio, 2010, Mikulak, 2020, Schroeder and Shidlo, 2002, Shidlo and Schroeder, 2002, Spitzer, 2003, Van Zyl, Nel and Govender, 2017, 2018, Weiss and others, 2010).

Evidence suggests that most people have conversion therapy voluntarily, although it can be initiated by parents or family members, members of their community or in some cases by therapists. People may seek conversion therapy for different reasons – those reported within our literature review include someone’s:^{[footnote 19]}

• belief that their sexual orientation is incompatible with their religious faith
• internalised stigma and shame associated with their sexual orientation
• fear and anxiety about the implications of being LGB
• unsuccessful or negative same-sex sexual experiences
• family, religious institution, psychotherapist or others in their social environment putting pressure on them

Studies do not examine if people’s motivations vary by gender, ethnicity or religion. No evidence was identified that specifically examined the motivations of those who undergo gender identity change efforts. A systematic review by Wright, Candy and King (2018) on gender identity conversion efforts identified only 4 articles, 3 of which relate to conversion therapy with transgender children at the request of their parents. The fourth article is a case study relating to a transgender adult who was seeking treatment for obsessive compulsive disorder in which the therapist claimed the treatment had shifted the client’s gender identity.^{[footnote 20]} In none of the cases described do the transgender clients appear to have sought out conversion therapy.

Findings from qualitative research

Similar themes from the evidence review were found in the accounts of our interviewees.

Religious reasons:

Religious reasons for having conversion therapy were most commonly given by interviewees who had difficulty reconciling their religious values with their sexual orientation. Many perceived their religious values to be incompatible with their sexual orientation and could not integrate their religious identity with an LGB identity. This internal conflict made them distressed and led them to try to change their sexual orientation. Feelings of religious guilt and shame were also common.

That’s when the real conflict started to happen, and a challenge in terms of how I integrated my religious faith with being gay, and feeling the shame, a huge amount of shame in being gay within a very conservative environment.

(Cisgender man, gay, 50s, sexual orientation change efforts)

Others sought sexual orientation change efforts out of fear of eternal damnation.

A desire to belong:

Another important factor for our interviewees was a strong desire to belong within their families, religious communities and friendship groups, and a belief that being LGB was an obstacle to that. Many interviewees had grown up belonging to a faith community. They described their whole life as revolving around the church and their social circle mainly consisted of others within their faith community. They sometimes referred to their faith community as being separate from mainstream society and described them as existing in ‘a bubble’.

These interviewees commonly sought conversion therapy out of a fear of being rejected by their community. Being heterosexual was considered the norm and interviewees reported that they had been driven to conversion therapy by a desperate desire to lead a ‘normal’ life. Being LGB was not only seen as incompatible with their faith, but sometimes also with other aspects of their identity. For example, one Black interviewee felt that his sexual orientation was not only incompatible with his faith but also with his ethnic identity.

When your church is your universe, you will do anything to stay in it because the consequence of being out of it is being basically abandoned. I think that’s one of the reasons why I embraced conversion therapy because I wanted to be part of the church community… being black as well and from the Afro-Caribbean community, there wasn’t any obvious queer role models I could look up to or if there were, they were often ridiculed by the wider black community. So, for me at a young age, I was taught wrongly that being queer and black was not compatible.

(Cisgender man, bisexual, 30s, sexual orientation change efforts)

A failure to connect and identify with other LGB people was also a motivating factor. This was due to a difficulty integrating their perception of LGB people (often based on stereotypes) with the norms of the groups they belonged to.

Negative sexual experiences:

Some male interviewees said that unfulfilling same-sex sexual experiences had influenced their decision to undergo conversion therapy. Some said that, because they were keeping their sexual orientation a secret, they engaged in secretive, one-off sexual encounters with strangers that would leave them feeling dirty, guilty and emotionally unfulfilled. They came to associate these experiences and emotions with being gay. Several interviewees also reported a history of unwanted same-sex sexual experiences which reinforced their negative associations with same-sex sexuality.

And then he stroked my leg, I felt really uncomfortable, but the thought that went through my head was ‘he knows I’m gay’, and I was like ‘I don’t want to be found out’… that pushed me further into denial of ‘I am not going to be like him’ because that’s what gay men are like, they’re predatory, I don’t want to be like that.

(Cisgender man, gay, 40s, sexual orientation change efforts)

Pressure or coercion from others:

Another factor that several interviewees reported was feeling pressured by members of their faith community to attend a course or read ex-gay literature. This happened even after they made it clear they did not wish to do so. Several participants also experienced coercion from their parents. For example, one young woman was locked in her bedroom for 3 days until she agreed to seek help to change her sexual orientation.

Although interviewees generally reported undergoing sexual orientation change efforts voluntarily, they also frequently reported being led into it under the guidance of people in a position of spiritual authority. Many felt that their ‘choice’ to undergo conversion therapy was influenced by people in their social environment in powerful positions.

I don’t think anybody chooses conversion therapy. I feel like they’re forced to choose it because the influences that they have are telling them that they need to, so that’s what happened with me. I felt like I was making a personal choice to go and do these things but when I look back on it I realise actually I was in a vulnerable position and didn’t have much self-confidence to know what I wanted or what was good for me so I listened to those people in authority over me who convinced me that that was the choice I needed to make.

(Cisgender woman, lesbian, 30s, sexual orientation change efforts)

Although there were only 6 transgender and non-binary interviewees, none of the transgender interviewees reported seeking out or requesting conversion therapy. 2 said psychiatrists treated their gender identities as if they were a symptom of their mental health condition (schizophrenia, PTSD) and 4 reported feeling pressured to engage in conversion efforts from family or religious leaders. In one case, a young transgender man reported feeling pressured by his grandparents to have conversion therapy with a priest. In the other 3 cases, they were initially welcomed into a church, but their church leaders began to express disapproval of their gender identity. They encouraged them to have pastoral counselling and eventually placed conditions on their participation in the church. One transgender interviewee was threatened with eviction from the house she was renting from her church if she did not change her gender expression.

It became clear that they [church leaders] didn’t approve of it and I was frequently encouraged to go and listen to talks. They proceeded to arrange for some counselling sessions with one of their pastoral team. I was encouraged to part with all my female wardrobe… they said to me that if I wanted to carry on living there, I really had to stop all this silly stuff.

(Transgender woman, heterosexual, 50s, gender identity change efforts)

Interviewees who were dependent on family members or their faith community, or those without a wide social support network, appeared to be particularly vulnerable to pressure and coercion.

6. What are the outcomes of conversion therapy?

This chapter outlines the evidence regarding the outcomes of conversion therapy in terms of whether it is effective at changing sexual orientation or gender identity, as well as whether it is associated with harms or benefits. Findings from the rapid evidence assessment will primarily be used to answer these questions. Data from the qualitative research conducted for this report will be presented to illustrate how perceptions of effectiveness can change over time as well as to illustrate the perceived harms and benefits of conversion therapy by those who have undergone conversion therapy in the UK.

6.1 Overview

The balance of evidence suggests that conversion therapy is unlikely to be effective and is associated with negative health outcomes.

There is very little robust evidence to support claims that conversion therapy can be effective in achieving its aim of changing a person’s sexual orientation or gender identity.

A number of studies have found very few people who undergo sexual orientation change efforts report any change. There are some studies that report higher levels of success, however, such studies have serious limitations or fatal flaws in study designs. Inconsistency in findings is likely due to a lack of scientific rigor.

Qualitative evidence has found that some individuals who have undergone conversion therapy report having been in denial about having changed. Some also report pretending to have changed in order to conform to others’ expectations. Self-reports of success should be interpreted with this in mind.

No recent evidence regarding the effectiveness of conversion therapy for changing gender identity was identified.

Some individuals report secondary benefits of conversion therapy (for example, social support, a sense of belonging). However, it is likely that these benefits are not unique to conversion therapy and could be attained through alternative therapeutic approaches that do not attempt to change a person’s sexual orientation or gender identity.

There is a growing body of quantitative evidence that exposure to sexual orientation change efforts is statistically associated with multiple negative health outcomes (including suicidal thoughts and suicide attempts). This body of evidence is larger for sexual orientation change efforts, however, one recent study has also found that gender identity change efforts are associated with similar negative health outcomes. Although we need to interpret this data with care, such associations are consistent with verbal accounts of individuals who have undergone conversion therapy.

6.2 Are conversion therapies effective?

Findings from rapid evidence assessment

Randomised controlled trials are the scientific gold standard for assessing the effectiveness of treatments. There are no randomised trials of conversion therapies. Evidence regarding whether modern forms of conversion therapies are effective at changing sexual orientation typically rely on surveys that retrospectively gather self-reported data regarding individuals’ sexual orientation after the conversion therapy. Due to a lack of controlled prospective studies, a reliance on self-reporting, potential sampling biases, a lack of objective measures, a lack of follow-up data and the inclusion of various conversion therapy methods within studies (see Appendix 2), published research does not meet scientific ‘gold standards’ for making robust claims about effectiveness .^{[footnote 21][footnote 22]} Therefore, there is no sound basis for claims that conversion therapy is effective at changing sexual orientation or gender identity.

Several systematic reviews have concluded that there is no robust evidence that conversion therapy is effective (APA, 2009a, Serovich and others, 2008) .^{[footnote 23]} The balance of evidence suggests that efforts to change sexual orientation are unlikely to be effective.

A systematic review conducted by the American Psychological Association’s Task Force on Appropriate Therapeutic Responses to Sexual Orientation (APA, 2009a) concluded that efforts to change sexual orientation appear unlikely to be successful. They suggested that some individuals may modify how they label their sexuality or change their sexual behaviour, but these changes might only be temporary. They go on to state that some individuals do become skilled at ignoring same-sex attractions and go on to lead ‘outwardly heterosexual lives’, however this appears to be less common among those who were not to some degree attracted to members of the opposite sex (for example, bisexual in orientation) prior to change efforts.

No studies published since 2000 were identified that assessed the effectiveness of conversion therapies seeking to change a person’s gender identity and any claims that it is possible to change a person’s gender identity are unproven.^{[footnote 24]}

These conclusions are consistent with more recent evidence. A number of studies (including the largest) have found that, even among those most motivated to change, respondents rarely report any modification of sexual orientation (for example, Bradshaw and others, 2015, Dehlin and others, 2015 and Maccio, 2011). For example, in the largest survey of its kind Dehlin and others (2015) found that only one respondent out of 1,019 (0.1%) who had undergone sexual orientation change efforts subsequently identified as ‘heterosexual’. No respondent reported the complete elimination of same-sex attraction and only 3% reported any change in their sexuality. Of those who did report some change, this was not always a change in sexual attraction but included modification of sexual behaviour (for example, not acting on same-sex attractions) or a change in how they thought about their sexual orientation (for example, that it did not define who they were). This study was based on self-report data and shares many weaknesses of other studies. For instance, we do not know whether the small minority who reported modification of their sexual behaviour maintained this over time.

There are inconsistent findings with some studies reporting higher levels of self-reported sexual orientation change (for example, Nicolosi, Byrd, and Potts, 2000b, Spitzer, 2003). However, even within these studies self-reported change appears to be incremental and reports of a complete change from exclusively same-sex oriented to exclusively heterosexual are rare. A lack of scientific rigor may explain inconsistent findings.

Previous systematic reviews suggest that studies reporting to find significant sexual orientation change are seriously methodologically flawed (APA, 2009a, Serovich, 2008). In addition to general methodological limitations that preclude any robust claims of effectiveness, one systematic review (APA, 2009a) found some studies were fatally flawed due to using unreliable measures and inappropriate statistical tests (for example, Jones and Yarhouse, 2007, and Nicolosi, Byrd, and Potts, 2000b).

Another study published in 2018, that reported significant shifts in sexual orientation, was subsequently retracted by the journal it was published in due to concerns over the statistical analyses (RETRACTED: Santero, Whitehead and Ballesteros, 2018).^{[footnote 25]}

Another study reporting significant change (Spitzer, 2003) has subsequently been repudiated by its own author. Spitzer (2012) has publicly accepted that criticisms of his study were largely correct, that it was impossible to answer questions of effectiveness with the study design used and that there was no way of determining if participants’ accounts of change were valid.^{[footnote 26]} Due to such methodological problems, findings of change are unpersuasive.

Few participants in published qualitative studies describe conversion therapy as successful (Fjelstrom, 2013, Johnston, and Jenkins, 2006, Shidlo and Schroeder, 2002, Van Zyl, Nel and Govender, 2017). Qualitative evidence cannot robustly answer the question of effectiveness, however, it can help us to interpret quantitative evidence. Qualitative studies have found some individuals describe perceived effectiveness of conversion therapy changing over time from an initial ‘honeymoon period’ through to ‘disillusionment’ (Fjelstrom, 2013, Shidlo and Schroeder, 2002, Van Zyl, Nel and Govender, 2017, and Weiss and others, 2010). As such, asking conversion therapy clients about effectiveness at one point in time is likely to be unreliable.

Findings from the qualitative research

This was also the case in the present study with UK interviewees. Most interviewees experienced no change in their sexual orientation or gender identity, perceived conversion efforts to have been a failure and subsequently went on to accept their same-sex sexual orientation or gender identity. Only 2 interviewees (one man and one woman) reported now identifying as heterosexual and were currently married to people of the opposite sex. While the man who identified as heterosexual at the time of interview believed himself to have been changed, the woman who identified as heterosexual was not confident the apparent change was a result of the conversion therapy. She believed it could have been due to natural sexual fluidity and reported some previous sexual attractions to men when she identified as lesbian.^{[footnote 27]}

Another man interviewed did not identify as gay but continued to experience same-sex attraction.^{[footnote 28]} Several others reported some minor changes, such as in their sexual behaviour or described their sex lives as less ‘compulsive’ but continued to experience same-sex attraction. Some of these interviewees considered conversion therapy to have been (at least partially) ‘successful’ on the basis of secondary therapeutic benefits (see Section 5.3). This included 2 interviewees who were periodically undergoing forms of conversion therapy at the time of interview.^{[footnote 29]}

Among the majority of interviewees who believed conversion therapy to have been a failure at the time of interview, many reported previously experiencing temporary perceptions of change due to expectation of change and being in denial.

Temporary perceptions of change

A number of interviewees reported periods of time while undergoing conversion therapy when they thought change had occurred but in hindsight attributed this to a short-term ‘placebo effect’ due to their expectation of change. Many who experienced conversion therapy in a religious context reported being told that they must have ‘faith’ for it to work, so tried to persuade themselves that they had been ‘healed’.

I think there is a placebo effect in it. They are so convinced it’s going to work, so for a very limited period of time, maybe days or weeks, not even a month you would have that feeling of maybe it did work.

(Cisgender woman, lesbian, 30s, sexual orientation change efforts)

Some interviewees described becoming skilled at distracting themselves (for example, through keeping busy) and had temporarily believed change had occurred but now believe that they were previously in denial.

I buried it really, pushed it down and carried on, got very busy, but it was still in the background…I think at the time I went ‘oh that’s it dealt with’, and so then I just ignored it and I very much was in denial for a long, long time because again I busied myself with church…I look back and think yeah actually you were really in denial.

(Cisgender man, gay, 40s, sexual orientation change efforts)

For some this process of denial took the form of outwardly acting as if change had occurred and declaring to others that it had. Others explained that they pretended that change had occurred to be accepted within their community or to please others. One gay man who had become co-leader of a conversion therapy course explained that the longer he deceived himself and others, the more difficult it became to openly admit that no change had occurred.

Such qualitative findings have implications for the interpretation of effectiveness studies. Self-reported success needs to be considered in light of developmental shifts in perceived effectiveness (Shidlo and Schroeder, 2002). In particular, studies that ask participants about the outcomes of conversion therapy at a single time point, particularly during or shortly after therapy, may not provide a reliable reflection of perceptions of effectiveness over the longer term.

6.3 Are there any benefits of conversion therapy?

Findings from rapid evidence assessment

Evidence regarding secondary benefits (such as benefits other than changing or minimising feelings or behaviour relating to sexual orientation or gender identity) comes in the form of retrospective self-report surveys and qualitative studies with people who have undergone conversion therapy (APA, 2009a, Beckstead, 2002, Nicolosi, Byrd and Potts, 2000b, Shidlo and Schroeder, 2002, and Throckmorton and Welton, 2005).

Conversion therapy advocates often claim that in addition to changing a person’s sexual orientation or gender identity, such ‘therapy’ can result in improvements in mental health. A systematic review concluded that there is no sound basis for claims that mental health or quality of life improve as a consequence of conversion therapy (APA, 2009a).

Nevertheless, benefits have been reported by some individuals within surveys and qualitative studies (for example, Beckstead, 2002, Nicolosi, Byrd and Potts, 2000b, Mikulak, 2020, Shidlo and Schroeder, 2002, and Throckmorton and Welton, 2005). Those studies conducted by conversion therapy advocates and that recruit through conversion therapy networks (for example, Nicolosi, Byrd and Potts, 2000b) appear to report more benefits than those that use other recruitment methods (for example, Bradshaw and others, 2015). The benefits reported include:

• Having a place to discuss conflicts and emotional distress
• Receiving empathy from others who understand the conflict they are experiencing
• Experiencing understanding and recognition of the importance of religious values
• Finding social support and interacting with others in similar circumstances
• Increased sense of belonging

It can be noted that many of these perceived benefits are not unique to conversion therapy but are common across most types of therapy and support groups (APA, 2009a). These benefits could potentially be gained through alternative therapeutic approaches that do not seek to change a person’s sexual orientation or gender identity (APA, 2009a, Wolkomir, 2001). A systematic review concluded that it is unlikely that sexual orientation change efforts provide any unique benefits other than those documented for social support groups generally (APA, 2009a). In several qualitative studies participants reported initially finding conversion therapy to be beneficial (for example, an increased sense of hope), followed by negative effects later (Beckstead and Morrow, 2004, Mikulak, 2020, Shidlo and Schroeder, 2002) (see Section 5.4).

Findings from the qualitative research

Although not a representative sample, the majority of the UK-based interviewees reported no benefits of engaging in conversion therapy, but a third reported experiencing some secondary benefits. These were reported mainly by cisgender men who had taken part in conversion therapy in a group setting with other men with unwanted same-sex attraction. The most common benefit reported was experiencing a sense of belonging and connection with other men in the same situation. In several cases, the group element provided an opportunity to meet other men like themselves which reduced their feeling of being different. For some it was the first time they had met other people with a same-sex sexual orientation. In some cases, lasting friendships were formed with those they met at conversion therapy weekend retreats and a sense of community was formed outside of the conversion therapy context.

I had always felt that I was a weird human being, that there was something wrong with me, and then suddenly I see all these great men, it was a feeling of being part of something.

(Cisgender man, gay, 50s, sexual orientation change efforts)

Some felt that the conversion therapy provided an opportunity for them to talk about other issues in their lives in much the same way one might benefit from speaking to any therapist or counsellor.

When you say how has the ministry helped, I think it’s in ways like that which are probably quite sensible, common sense sort of ways of dealing with things that anybody, any therapist would probably help you with, but that’s what I mean, and this isn’t a professional ministry if you like, but it’s still helped me even today with things that aren’t to do with sexuality.

(Cisgender man, heterosexual, 30s, sexual orientation change efforts)

These findings fit evidence from the rapid evidence assessmentand suggest that many of the perceived benefits some people gain from conversion therapy could be gained by other means such as participating in support groups for LGBT people of faith or speaking to a professional therapist who follows best practice guidelines.

6.4 Is conversion therapy harmful?

Findings from rapid evidence assessment

A growing number of studies are finding that exposure to conversion therapies is associated with multiple indicators of poor health for both sexual orientation and gender identity change efforts (Blosnich and others, 2020, Dehlin and others, 2015, Meanley and others, 2020, Ryan and others, 2018, Salway and others, 2020, Turban and others, 2020).

A wide range of harmful effects have also been reported within surveys and in qualitative research with people who have been through sexual orientation change efforts (APA, 2009a, Beckstead, 2002, Beckstead and Morrow, 2004, Bradshaw and others, 2015, Fjelstrom, 2013, Flentje, Heck and Cochran, 2014, Mikulak, 2020, Shidlo and Schroeder, 2002, Van Zyl, Nel and Govender, 2017, Weiss and others, 2010).

A previous systematic review concluded that there was evidence – mainly from qualitative studies – that some people think they have been harmed by conversion therapy. However, methodological limitations prevented definitive conclusions from being made (APA, 2009a).^{[footnote 30]}

There is stronger evidence from studies that make comparisons with LGBT people who have not had conversion therapy and show statistical differences in mental health outcomes. Within these studies, exposure to sexual orientation change efforts is consistently linked to higher likelihood of suicidal thoughts and suicide attempts compared with LGB people who have not had conversion therapy (Blosnich and others, 2020, Dehlin and others, 2015, Ryan and others, 2018, Salway and others, 2020).

One recent study found that, compared with sexual minority adults with no experience of sexual orientation change efforts, people who had undergone conversion therapy:

• were twice as likely to have had suicidal thoughts
• had 75% increased odds of planning to attempt suicide
• had 88% increased odds of attempting suicide resulting in minor injury
• had 67% increased odds of attempting suicide resulting in moderate or severe injury (Blosnich and others, 2020)

Particular strengths of this study include its random probability-based sample.

There is also recent evidence that gender identity change efforts are associated with similar negative health outcomes. A large US-based study with 27,715 respondents found that exposure to gender identity conversion efforts by secular professionals or religious advisors is significantly linked with increased odds of reporting severe psychological distress and suicide attempts, compared with transgender adults who had discussed gender identity with a professional but who were not exposed to conversion therapy (Turban and others, 2020). No significant differences were found when comparing exposure to gender identity change efforts delivered by secular professionals with therapy delivered by religious advisors. The strengths of this study include its large sample size and the high completion rate. However, the study lacks data regarding the degree to which conversion therapy occurred (for example, the duration, frequency and forcefulness) or what techniques were used. It was also a self-selecting sample.

There is also a need to be careful when making causal interpretations from such studies. For example, an alternative explanation could be that LGBT people with mental health problems are more likely to seek out conversion therapy. However, one study controlled for adverse childhood experiences (for example, physical or sexual abuse) that are also associated with suicidal thoughts (Blosnich and others, 2020).

Another study found that negative health outcomes were much more likely for people who had experienced both parental attempts to change their sexual orientation and conversion therapy from a therapist or religious counsellor, compared with people who had experienced only one of these (Ryan and others, 2018). On the basis of this evidence, alternative explanations for this finding are less plausible than the conclusion that conversion therapy has a negative impact on mental health.

The authors of these studies have tended to explain the associations between conversion therapy and negative health outcomes using the minority stress model (Meyer, 1995, 2003). There is increasing evidence that stigma associated with minority sexual orientations and gender identities (manifested as prejudice and discrimination) is a major source of chronic stress that can have negative mental health consequences for LGBT people including suicidal thoughts (Baams, Grossman and Russell, 2015, McNeil, Ellis and Eccles, 2017, Meyer, Frost, Nezhad, 2015).

Conversion therapy by its nature and purpose promotes the rejection of minority sexual orientations and gender identities. It might therefore reinforce and contribute to self-rejection, internalised stigma and their associated negative health outcomes (APA, 2009a, Blosnich and others, 2020).

This interpretation of the evidence also fits with reports of perceived harm within qualitative studies with people who have undergone conversion therapy (APA, 2009a, Beckstead, 2002, Beckstead and Morrow, 2004, Bradshaw and others, 2015, Fjelstrom, 2013, Flentje, Heck and Cochran, 2014, Shidlo and Schroeder, 2002, Van Zyl, Nel and Govender, 2017, Weiss and others, 2010).

Reported harmful outcomes include:

• depression and feeling suicidal
• decreased self-esteem and increased self-hatred
• self-blame for treatment failure
• feelings of guilt and shame
• social isolation and loss of social support
• deteriorated family relationships
• a loss of faith
• wasted time and resources

In addition, participants in qualitative studies clearly put these harmful outcomes down to the conversion therapy. Although qualitative research cannot robustly answer the question of whether conversion therapy is harmful, it can provide some indication of why it might be experienced as such. Those who perceived conversion efforts to have been a failure, while believing that change was possible, reported blaming themselves, experiencing poor self-image and emotional distress (APA, 2009a).

Findings from the qualitative research

The findings from the rapid evidence assessment (of mostly North American studies) can also be seen in our qualitative research with UK interviewees. Most interviewees said they thought their conversion therapy had been harmful. Many believed that conversion therapy reinforced their feelings of stigma and shame and undermined their mental health. They said conversion therapy had negatively affected their self-esteem and that messages conveyed during conversion therapy had left many feeling there was ‘something wrong’ with them.

Most spoke in general terms about how the conversion therapy made them feel rather than attributing harm to specific techniques, although several interviewees referred to exorcisms as being ‘traumatic’. They also said the inaccurate and negative representations of LGBT people by conversion therapists had reinforced stereotypes and negative associations with their sexual orientation or gender identity.

Depression, suicidal thoughts and self-harm:

Many interviewees said that had experienced depression, suicidal thoughts and in some cases had attempted suicide. Many said that conversion therapy has made the internal conflict between their faith and their sexual orientation or gender identity worse, and prolonged their lack of self-acceptance.

I was suicidal and self-harming at one point and then I made the conscious decision to not have anything more to do with conversion therapy, because all I was seeing was suicide, self-harm and depression in the people around me, and not seeing anyone change.

(Cisgender man, gay, 30s, sexual orientation change efforts)

I would hurt myself, I would self-harm.

(Transgender woman, pansexual, 20s, sexual orientation change efforts and gender identity change efforts)

Some interviewees also self-harmed and restricted their eating as a result of stress caused by conversion therapy. One cisgender man reported engaging in substance abuse and risky sexual behaviour that ultimately led to him contracting HIV. He said his risky behaviour was due to feelings of worthlessness caused by conversion therapy. Although it is not possible to determine whether such behaviour was due to either the interviewees not accepting their sexual orientation or the conversion therapy itself, they were thought to be interlinked. This is because conversion therapy actively encouraged them to not accept their sexual orientation.

Many interviewees said their mental health improved after ending conversion therapy. Many went on to find support and learned to accept their sexual orientation or gender identity, for example through finding LGBT affirmative religious groups.

Self-blame:

When efforts to change sexual orientation were unsuccessful, interviewees reported feeling a sense of failure and would initially blame themselves rather than the conversion therapy.

The more it didn’t work the more I started to feel like, well there must be something wrong with me because they are so convinced it’s working, and they’re so convinced it has happened for other people. Well why isn’t it for me? I must be so bad and so sinful that I’m beyond God’s redemption.

(Cisgender woman, lesbian, 30s, sexual orientation change efforts)

Interviewees reported that the person leading the conversion efforts would suggest that success was dependent on their level of religious faith or commitment. In some cases, this led the interviewees to blame themselves rather than question the conversion therapy.

Feelings of anger and resentment:

Interviewees also reported that conversion therapy had delayed their social, emotional and sexual development. Some felt anger and a sense of loss for the years they could otherwise have spent in healthy, happy same-sex relationships if people in authority had accepted them more.

There is a lot of anger to do with the fact I feel that the best years of my life were stolen or given to a belief which meant that I was single and celibate, and you can never have those years back.

(Cisgender woman, lesbian, 50s, sexual orientation change efforts)

Social isolation:

Another common harmful effect of conversion therapy reported by interviewees was social isolation both during and after conversion therapy. Several interviewees received advice to distance themselves from LGBT or ‘liberal’ friends as a way of avoiding ‘corrupting’ influences. Some were also advised not to disclose their sexual orientation to others.

Such advice led them to become socially isolated and prevented them from accessing social support from alternative sources such as peers. In a number of cases, interviewees who decided to stop their efforts to change and accept their sexual orientation or gender identity found themselves excluded by their faith community and lost their whole social support network.

I was effectively ex-communicated, because it wasn’t working. I’d had a whole community that I’d grown up with, there were people that I trusted, there were people that I saw as role models, and they all were taken away in one go.

(Cisgender man, gay, 40s, sexual orientation change efforts)

Others took the initiative to leave their faith community to escape the pressure to change. However, this loss of community was still experienced as painful and socially isolating.

Damaged family relationships:

Several interviewees said that conversion therapy affected their relationships with their parents, particularly due to suggestions that their sexual orientation or gender identity was caused by poor parenting, childhood trauma or abuse. For example, in one case the interviewee’s pastor suggested that he may have repressed memories of being abused by his father which put a strain on their relationship.

For a good few years afterwards I almost doubted my memory, so it did pull me further away from my parents. I had this memory almost implanted in me. It did put a rift between my dad and I for a while, I don’t think he’d realised why, but I emotionally detached myself from him for quite a while because constantly every time I saw him, I thought about it.

(Cisgender man, gay, 20s, sexual orientation change efforts)

The harmful outcomes reported in our qualitative interviews reflect those identified from the rapid evidence assessment and illustrate that harmful outcomes are directly attributed to conversion efforts by those who undergo them.

7. What measures have been taken to end conversion therapy around the world?

This chapter provides an overview of the different types of legislative measures taken around the world to end conversion therapy, what legal challenges they have faced and what effect they have had. This section is based on desk research from a search of the grey literature.^{[footnote 31]}

7.1 Overview

The number of legal jurisdictions passing legislation to restrict or end conversion therapy is growing rapidly. Measures taken include the following:

Legal bans or restrictions

A growing number of countries have nationwide laws (Brazil, Ecuador, Germany and Malta) or sub-national laws (Canada, Spain, USA) that ban or restrict the practice of conversion therapy. These vary in scope from those that apply only to conversion therapy conducted by health professionals with minors, to others that are more comprehensive in nature.

Regulation of health professionals

A number of jurisdictions regulate health professions in ways to prevent the provision of conversion therapy by health professionals (Albania, Argentina, Uruguay, Fiji, Nauru, Samoa and Switzerland). This can function as an indirect ban on healthcare professionals providing conversion therapy.

Child protection legislation

Several jurisdictions have proposed that parental forms of conversion therapy may, in certain circumstances, be considered a form of parental abuse and could fall within child protection law. Some bans have also specifically focused on conversion therapy conducted with minors to protect children.

Equality and anti-discrimination legislation

Several jurisdictions have included provisions regarding conversion therapy in equality laws that prohibit discrimination on the basis of sexual orientation and gender identity.

Consumer protection legislation

Court cases have been successfully brought against conversion therapy providers under existing consumer protection law (for example, New Jersey, USA).

Some legal restrictions on conversion therapy prevent services charging for ‘fraudulent’ conversion therapy (Vancouver, Canada).

Advertising regulation

Some legal restrictions include the prohibition of advertising conversion therapy (for example in Brazil and Malta).

Health insurance legislation

Several jurisdictions have prohibited health insurers from providing coverage for conversion therapies (for example, Ontario, Nova Scotia and Edward Island in Canada)

There is little evidence on the impact of these measures or how well they are enforced. However, in one jurisdiction with a comprehensive ban (Madrid, Spain) a life coach offering conversion therapy has been fined. It is unlikely that action would have been successful under jurisdictions with bans more limited in scope.

7.2 What kind of measures have been undertaken?

A growing number of countries and legal jurisdictions are passing legislation to restrict or end conversion therapy (Drescher and others, 2016, ILGA, 2020).

A number of legislative approaches have been taken around the world, including legal bans on conversion therapy and the use of existing legislation to bring legal proceedings against conversion therapy providers. Some legislative approaches also seek to restrict conversion therapies through regulatory measures such as regulating health professionals, advertising or health insurance. Table 4 provides a typology of legislative approaches taken (see Appendix 3 for a more detailed summary of legislative measures by jurisdiction and a list of sources).^{[footnote 32]}

Table 4: Legal measures to end conversion therapy

Type of measure	Description	Example jurisdictions
Legal bans or restrictions	Legislation to restrict or end conversion therapy. The breadth and scope of such legislation varies, as do the penalties imposed. Some apply only to health professionals (Germany, Ontario, Nova Scotia, Prince Edward, Murcia), specific professionals (for example, psychologists, such as in Brazil) or particular healthcare settings (for example, addiction rehabilitation centres, such as in Ecuador). Some apply only to conversion therapy practiced with minors (for example, Germany, Malta and laws in most Canadian provinces and US states). Some are more comprehensive and apply to any form of conversion therapy without qualifying providers or recipients (the Spanish regions of Andalusia, Aragon, Madrid and Valencia and the Canadian city of Edmonton).	Brazil Ecuador Malta Germany Canada (3 provinces) Spain (5 regions) USA (20 states)
Regulation of healthcare professions (de facto bans)	Laws that regulate health care professions in ways that prohibit registered professionals from providing conversion therapy. These function as indirect bans. Professionals who violate such regulations face disciplinary procedures and may have their license or registration revoked. In some countries psychotherapists and life coaches are not regulated health professions and so do not fall within the scope of such regulation.	Argentina Uruguay Samoa Fiji Nauru Switzerland
Child protection legislation	Child protection laws to establish that attempts by parents or legal guardians to change a child’s sexual orientation or gender identity constitute a safeguarding concern.	Chile (proposed bill) Taiwan
Equality and anti-discrimination legislation	The application of equality legislation or the amending of anti-discrimination law to explicitly define conversion therapy as an act of discrimination against LGBT people.	Chile (proposed bill) Spain (5 regions)
Consumer protection legislation	The application of consumer rights legislation to paid-for conversion therapy. Conversion therapies may be deemed fraudulent practices due to being based in pseudo-science or for deceptive or inaccurate claims in its advertising. Consumer rights provisions may also be included within new laws designed to restrict conversion therapy.	Vancouver (Canada) Illinois (USA) Connecticut (USA) New Jersey (USA)
Advertisement legislation	Legislation that bans, restricts or regulates the advertisement or promotion of conversion therapy. A number of bans include provisions that specifically prohibit advertising.	Brazil Malta
Health insurance legislation	Restricting conversion therapy by prohibiting health insurers from providing coverage for such treatments, for example on the basis that homosexuality is not a diagnosable mental health condition, that conversion therapies are not effective treatments or that healthcare professional bodies do not endorse them.	the Netherlands Ontario (Canada) Nova Scotia (Canada) Prince Edward Island (Canada) New York City (USA)

Legal bans or restrictions

Legislative measures to restrict conversion therapy vary in their scope and legal character in relation to whether they are limited to specific types of providers or recipients. Many laws are fairly limited in scope applying only to conversion therapy by specific providers or when delivered with particular groups of recipients.

Many laws are limited to conversion therapy provided by licensed health professionals (Germany, Ontario, Nova Scotia, Prince Edward, Murcia). Legislation in Brazil is even further limited in scope, applying only to licensed psychologists. The law in Ecuador applies only to conversion practices within addiction rehabilitation centres (other than extreme forms that would constitute ‘torture’ in Ecuadorian law). The law in Nova Scotia, Canada applies primarily to health professionals but also includes non-professionals ‘in positions of trust or authority’ which could include religious leaders.

Most measures enacted also only apply to conversion therapy carried out with minors (for example, Germany and most Canadian provinces and US states that have laws). Malta’s law is slightly broader applying to conversion therapy with any ‘vulnerable person’ (including anyone under 16 years of age, people with mental health conditions or anyone deemed so by a court taking into account their personal circumstances).

The bans in force in Madrid, Andalusia, Aragon and Valencia in Spain – as well as one in Edmonton, Canada – are the most all-encompassing bans so far. They apply to any intervention that aims to change a person’s sexual orientation or gender identity (including religious counselling) without qualifying providers or recipients (ILGA, 2020).

Legislation that specifically bans or restricts conversion therapy does not always appear as specific laws on conversion therapy but may take the form of provisions within or amendments of existing legislation. For example, the Isle of Man is in the process of amending a sexual offences and obscene publications bill to include a clause that would ban conversion therapy.

Child protection legislation

Child protection laws have been used to restrict conversion therapy. For instance, in 2018 the Taiwanese Ministry of Health and Welfare issued a letter to local health authorities stating that any individual performing conversion therapy on children may be liable for prosecution under the Protection of Children and Youths Welfare and Rights Act. A bill proposed in Chile in 2019 would also define parental attempts at conversion therapy as a safeguarding issue by characterising them as acts of domestic violence.

Equality and anti-discrimination legislation

The application of anti-discrimination law to conversion therapy has been proposed. For instance, in 2019 a proposed bill brought forward in Chile characterised parental attempts at conversion therapy as an ‘act of arbitrary discrimination’. The bans on conversion therapy in 5 Spanish regions also appear as provisions within omnibus social equality laws for protecting LGBT people from discrimination.

Consumer rights legislation

There have been a number of lawsuits brought against conversion therapy providers using consumer protection law (for example, Ferguson and others vs JONAH and others, Dubrowski, 2015). There are also sub-national bans that prohibit the charging of a fee for services that seek to change a person’s sexual orientation or gender identity on the basis that they constitute fraudulent practices (for example, Vancouver, Canada).

Regulation of healthcare professions

Several jurisdictions have introduced laws that regulate health care professions in ways that prohibit professionals from diagnosing someone with a mental illness based exclusively on their sexual orientation or gender identity (Argentina, Fiji, Nauru, Uruguay and Samoa).

Although these laws do not explicitly ban conversion therapy, they can function as indirect bans that effectively prevent conversion therapy being delivered by mental health professionals within healthcare settings. Those who violate these regulations may face disciplinary measures and risk having their licenses or registration to practice revoked. These indirect bans only apply to regulated professions. In some countries, such as the UK, psychotherapists and life coaches are not regulated professions and so would not fall within the scope of regulation.

Advertisement legislation

Several legal bans on conversion therapy around the world include the prohibition of advertising or the promotion of conversion therapy (for example, Brazil and Malta, and Andalusia, Aragon, Madrid and Murcia in Spain).

Health insurance legislation

Several jurisdictions have also opted to restrict conversion therapy by prohibiting health insurers from providing coverage for such treatments.

For example, in 2012 the Dutch health minister announced that healthcare insurance coverage did not need to cover conversion therapies as homosexuality was not a psychiatric diagnosis.

A number of subnational bans also prohibit conversion therapies from being considered ‘insured services’ (for example, Ontario, Nova Scotia and Prince Edward Island in Canada, and New York City, USA). A bill currently being considered at a federal level in the USA would also ban the use of Medicaid funding to cover conversion therapy.

7.3 What legal challenges have these measures faced?

To date, no final judicial decision has overturned a ban on conversion therapy. There have been several ultimately unsuccessful attempts to overturn US state laws. Arguments used by those opposed to legislative restrictions have been based around the right to self-expression, parental rights and religious rights. Although these are indicative of the type of arguments that any ban on conversion therapy might encounter, it is important to note that these challenges were brought under a different legal system and were subject to different legal tests than would be the case in the UK. In particular, the jurisdictions were not signatories to the European Convention on Human Rights, which may impose a higher level of scrutiny. Although preliminary injunctions were initially successful, both cases were unsuccessful at a court of appeal (see Table 5).

Table 5: Legal challenges and arguments

Legal Challenge	Jurisdiction and year	Plaintiff arguments	Court reasoning
Pickup and others v. Brown and others and Welch and others v. Brown and others	California, 2013	Freedom of speech: Plaintiffs argues that the law infringed conversion therapists’ right to free speech. Parental rights: Plaintiffs claimed that the law violated parents’ right to direct the upbringing of their children.	Freedom of speech: The court judged that the law regulates conduct not speech and that while communication that occurs during therapy was entitled to protection under the US constitution, it was “not immune from regulation”. Further, they note that the law was adopted “for the important purpose of protecting public health, safety and welfare”. Parental rights: The court judged that while it did not dispute the fundamental right of parents to raise their children as they see fit, that the Plaintiffs “cannot compel the State to permit licensed mental health [professionals] to engage in unsafe practices, and cannot dictate the prevailing standard of care”.
King and others v. Christie and others	New Jersey 2014	Freedom of speech: Plaintiffs claimed that the law violated freedom of speech because conversion therapy is administered through verbal communication. Freedom of religion: Plaintiffs claimed that the law violated their free exercise of religion because it covertly targets their religion by prohibiting counselling that is generally religious in nature.	Freedom of speech: The court reasoned that the law regulates conduct not speech and that there was nothing to prevent professionals voicing their opinions in public or private, provided they did not practice conversion therapy. Furthermore, they stated that therapy was not immune from regulation on the basis of it being delivered by the spoken word. Freedom of religion: The court reasoned that the “right to freely exercise one’s religion…does not relieve an individual of the obligation to comply with a ‘valid and neutral law of general applicability”. They reasoned that the law was based on the legislature’s neutral concern that conversion therapy is harmful and was of general applicability because it applied regardless of whether the provider or the recipient was motivated by religion.

A number of further challenges are still in progress in the United States (ILGA, 2020). As many of the legislative measures around the world have been recently introduced it is possible that further challenges may occur in years to come.

7.4 What effect have these measures had?

No published studies were identified that specifically examined the effect of these measures and it is unclear to what extent laws to restrict conversion therapy are enforced. Due to the recent nature of many of the legal measures, little is known about what impact they have had on conversion therapy practices. The law in Madrid (one of the most all-encompassing laws) has been successfully enforced resulting in a conversion therapist being fined (see Box 1).

Box 1: Case Study - Madrid

In 2019, the Community of Madrid fined a life coach €20,001 for offering conversion therapy via their website. The strap line for the website was “Yes, you can regain your heterosexuality” and the individual described herself as a ‘coach’ specialising in working with people with same-sex attraction and people addicted to pornography. In 2016 a complaint was filed by the LGBT rights group Arcópoli in which they presented the contents of the life coach’s website to the authorities. An investigation was launched during which further complaints were made by 2 individuals claiming the coach had offered to cure them of their same-sex attractions. After a 3-year process, in 2019 the coach was found to have violated Madrid’s Comprehensive Protection Law against LGBTIphobia and Discrimination (2016) and was fined the minimum sanction for a ‘very serious’ infraction of the law. The sanction was hailed by LGBT rights groups as a “historic and pioneering sanction”.

The successful action in this case was possible due to Madrid’s comprehensive approach which applies to any intervention that aims to change a person’s sexual orientation or gender identity without qualifying providers or recipients and also prohibits the promotion of conversion therapies. It is possible that this case would not have been successful under jurisdictions that apply only to registered health professionals as life coaching is often not a regulated health profession.

Source: El Pais (2019)

Several successful lawsuits have also been brought against conversion therapy providers in the USA and China using existing legislation such as consumer protection law. For example, in 2015 JONAH (Jews Offering New Alternatives to Homosexuality) was found to have violated the New Jersey Consumer Fraud Act by fraudulently claiming to provide “services that could reduce or eliminate same-sex attraction”. The organisation was ordered to cease operating and to dissolve (Dubrowski, 2015). In 2018, the defendants were found to be in breach of the order by operating under a new name (Jewish Institute for Global Awareness) and were ordered to pay damages.^{[footnote 33]}

An international report by ILGA (2020) has documented how other conversion therapy providers are rebranding and adapting their public-facing messages in light of ever-growing legislative measures to restrict their practices (see also Outright Action International, 2019). In addition to those documented elsewhere, the international coalition group for ex-gay organisations recently changed its name from ‘Positive Alternatives to Homosexuality’ (PATH) to ‘Positive Approaches To Healthy Sexuality’.^{[footnote 34]}

ILGA (2020) note that many providers now deny they deliver ‘conversion therapy’, even accepting that conversion therapy is harmful, but continue to operate in the same way. Some organisations state that changing a person’s sexual orientation or gender identity is not their primary aim but maintain that change is possible and may occur alongside treatment. For example, the Reintegrative Therapy Association, led by the son of reparative therapist Joseph Nicolosi, claims on its website that ‘reintegrative therapy’ is “entirely separate from conversion therapy” and that it aims to treat trauma and addiction rather than sexual orientation. However, it then goes on to state that “as these dynamics are resolved, the client’s sexuality can sometimes change on its own”.^{[footnote 35]}

Some groups also avoid referring to homosexuality and gender incongruence as ‘disorders’ on their websites, instead using terms such as ‘healthy sexuality’, ‘sexual brokenness’ and ‘gender confusion’. ILGA (2020) has also noted that some forms of conversion therapy brand themselves in ways that imply they cause no harm. For example, one approach (that is advocated by a Christian ex-gay organisation in the UK^{[footnote 36]}) is called ‘Sexual Attraction Fluidity Exploration in Therapy’ and is abbreviated to ‘SAFE-T’. When introducing measures to restrict conversion therapies, legislators should therefore consider ways in which organisations may rebrand and alter their public-facing messages.

8. Conclusions

In this section, we:

• discuss some of the policy implications of our findings
• consider gaps in the evidence identified by our rapid evidence assessment

8.1 Summary by research question and type of conversion therapy

Research question 1: What forms does conversion therapy take?

Sexual orientation change efforts:

Tended to be run by faith groups, mental health professionals or family members. They often take the form of talking therapies or spiritual guidance and intervention.

Gender identity change efforts:

Limited evidence is available but some conversion therapists appear to consider all LGBT people to have a form of gender disorder.

There is some evidence that conversion therapy for transgender people tends to be delivered in a similar way to SOCE (for example, talking therapies or religious interventions).

Research question 2: Who experiences conversion therapy and why?

Sexual orientation change efforts:

No representative prevalence data exists specifically for sexual orientation change efforts. The best available data from the UK suggests that around 2% of cisgender LGB respondents had undergone conversion therapy and a further 5% had been offered it. However, it is not possible to confirm whether the change efforts experienced by cisgender LGBT respondents were specifically directed at changing sexual orientation (or their gender identity).

Those exposed to sexual orientation change efforts tend to have a strong religious faith. Motivations for seeking conversion therapy tend to be associated with conflict about sexual orientation.

Gender identity change efforts:

No representative prevalence data exists but some evidence (from the UK and the USA) suggests that transgender respondents may be more likely to be offered or receive conversion therapy than cisgender sexual minorities. The best available data from the UK suggests that 4% of transgender respondents had undergone conversion therapy and a further 8% had been offered it. As with sexual orientation change efforts, it is not possible to tell whether change efforts were directed at changing transgender respondents’ gender identity or their sexual orientation.

Research question 3: What are the outcomes of conversion therapy?

Sexual orientation change efforts:

There is no robust evidence that conversion therapy can change sexual orientation. There is consistent evidence of self-reported harm associated with conversion therapy.

Gender identity change efforts:

There is no evidence that conversion therapy can change gender identity. There is limited but reasonably strong evidence that self-reported harm is associated with conversion therapy.

Research question 4: What measures have been taken to end conversion therapy around the world?

Sexual orientation change efforts:

An increasing number of legal jurisdictions have introduced measures to restrict or ban sexual orientation change efforts. These vary in their scope. Some bans have also included a ban on advertising conversion therapy. There is limited evidence on the effectiveness of these measures. Successful legal action challenging conversion therapy relates to sexual orientation change efforts.

Gender identity change efforts:

Many legal measures used to restrict conversion therapy appear to apply to both sexual orientation and gender identity change efforts. Some jurisdictions initially brought in measures that applied only to sexual orientation change efforts, and later extended them to include gender identity change efforts.

8.2 Policy implications

Given that conversion therapy is commonly based on inaccurate information about sexual orientation and gender identity, there is scope for raising awareness among healthcare professionals and faith groups.

Evidence that some mental health professionals might mistake minority sexual orientations and gender identities as symptoms of existing mental health conditions suggests that health professionals may benefit from training on issues of gender and sexual diversity (BPS, 2019).

Conversion therapy can take many different forms, take place in a range of settings and may not openly present itself as ‘conversion therapy’. Policy on conversion therapy should consider the ways that conversion therapy can manifest itself.

Although most people who have conversion therapy appear to do so voluntarily, they also describe being led into conversion therapy by people in a position of authority in their religious institutions or families.

In addition, a number of unethical practices by people in positions of authority were documented by UK interviewees, including:

• being given inaccurate information, affecting their ability to give full and valid consent
• being coerced to have conversion therapy
• being asked to sign non-disclosure agreements
• in one case, sexual assault by a conversion therapist

Several interviewees said what they had gone through was a type of ‘spiritual abuse’. This suggests that a particular focus of policy could be around working with organisations to prevent the abuse of positions of trust and authority.

There is increasing evidence that conversion therapy may be harmful. Evidential reasoning would also suggest by its nature and purpose conversion therapy is likely to reinforce and contribute to self-rejection and internalised stigma that is associated with minority stress and negative health outcomes (APA, 2009a).

An APA task force (2009a) suggested that aspects of conversion therapy that should be avoided include:

• overly directive treatment that insists on changing a person’s sexual orientation
• the communication of inaccurate, stereotypic or unscientific information
• the use of unsound and unproven interventions and misinformation on treatment outcomes

Policy could seek to target these most problematic aspects of conversion therapy.

There is little evidence on what legislative measures to end conversion therapy are effective. However, given that much conversion therapy appears to take place in religious settings, legislation that applies only to health professionals is likely to have only a limited impact on ending conversion therapy. Policy makers should bear in mind the way in which conversion therapy providers may rebrand and change their public-facing message in response to criticism and legal restrictions.

In addition to legislative measures to ban or restrict conversion therapy, policies could focus on developing constructive dialogue with religious groups. This could be used to educate them about the harmful effects of conversion therapy and encourage alternative approaches to pastoral guidance with LGBT people of faith.

8.3 Evidence gaps

Our rapid evidence assessment identified the following gaps in the evidence base.

Prevalence of conversion therapy

There is a lack of representative data due to self-selected samples and lack of representative data on the LGBT population in the UK.

Experiences of sexual and gender minorities beyond people identifying as LGBT

Further research is needed to examine the conversion therapy experiences of asexual, non-binary and intersex people, and health professionals’ attitudes towards people who identify as such. Further research is also needed into the conversion therapy experiences of people with same-sex attractions who do not identify as LGB.

Conversion therapy experiences of ethnic minority groups and those from non-Christian faiths

More information is needed to understand the forms that conversion therapy takes among these groups.

Evidence relating to gender identity change efforts

There is relatively little evidence on gender identity change efforts. Further research could specifically examine transgender people’s experience of conversion therapies and the forms it takes. Additional research on the harmful effects of gender identity change efforts would also be useful.

Lack of ‘gold standard’ evidence on effectiveness

No randomised control trials of conversion therapy exist. However, such designs are practically and ethically difficult to carry out in relation to conversion therapy and it is unlikely that any will be conducted in future. Lower quality evidence and evidential reasoning may need to be relied on when making policy decisions.

Impact of legislative and non-legislative measures

Comparison data before and after legislative measures would help determine their effectiveness in ending conversion therapy. Research on the effectiveness of non-legislative measures such as awareness raising, education and training programmes would also help inform policy making.

In addition to the evidence presented in this report, future research addressing the evidence gaps identified above could help inform future policy making.

1. Memorandum of Understanding on Conversion Therapy in the UK Version 2 October 2017 (see also Drescher, 2002 for a discussion of ethical issues). ↩

2. Some interviewees had experienced conversion therapy more than once or over a prolonged period. None of the interviewees’ experiences included historic forms of aversion therapy. No major differences were noted in the experiences of those who had undergone conversion therapy in the last 10 years compared to those who had experienced it 10 to 20 years ago. Several individuals were excluded from the study as part of the screening process as they did not fit our working definition of conversion therapy (for example, the treatment they underwent did not aim to change their sexual orientation or gender identity). ↩

3. Most of the evidence has examined conversion therapy in Christian or Jewish contexts, although such beliefs may also be a feature of other religions. ↩

4. For instance, the term ‘reparative therapy’ (developed by Joseph Nicolosi) conveys the idea held by conversion therapists that same-sex sexual orientations are caused by an unconscious attempt to ‘repair’ unmet needs and gender identification deficits (Nicolosi, 1991, and Nicolosi, 2001). ↩

5. For example, the British theologian Elizabeth Moberly (1983), whose work influenced reparative therapists such as Joseph Nicolosi, stated that “transsexualism in both sexes has the same psychodynamic structure as homosexuality. The difference is essentially one of degree, not of kind” (p. 12-13). ↩

6. The academic literature disproportionately represents experiences from the global North and North America in particular. The grey literature suggests more extreme forms of conversion therapy including ‘corrective rape’, electric shock aversion therapy and medical interventions occur in other parts of the world including parts of Africa, Asia and the Middle East (Madrigal-Borloz, 2020, Outright Action International, 2019). ↩

7. The British theologian Elizabeth Moberly (1983) was influential in combining psychoanalytic and religious approaches. Her book Homosexuality: a new Christian ethic was a significant influence on the US clinical psychologist Joseph Nicolosi. She later claimed he had plagiarised her work and took credit for the development of ‘reparative therapy’ (Throckmorton, 2019). ↩

8. The organisations are all signatories of a Memorandum of Understanding on conversion therapy. ↩

9. Although some forms of gender identity change efforts appear to be associated with religious ex-gay organisations (Robinson and Spivey, 2019), the grey literature suggests that other forms of conversion therapy may be more specific to transgender people. For instance, there have been reports of people sharing lists online of therapists for parents of transgender children seeking non-affirming therapists (Greenesmith, 2020, ILGA, 2020) (see also Ashley, 2019). ↩

10. Causal theories reported to have been offered by conversion therapists are not based on robust empirical evidence. ↩

11. Note: Respondents could select multiple responses. %s shown are of the survey respondents who had received conversion therapy. A further 11% indicated that they ‘preferred not to say’ who conducted it. ↩

12. Although not meeting the inclusion criteria for the rapid evidence assessment, respondents of the Ozanne Foundation’s UK-based 2018 Faith and Sexuality survey found that of those respondents with experience of sexual orientation change efforts, only a small minority had sought the advice of a health professional such as their GP (5%) or an NHS Psychotherapist (3%) compared to nearly half (47%) who had sought advice from a religious leader (Ozanne Foundation, 2019). ↩

13. The professional bodies surveyed have subsequently all issued position statements on conversion therapy as well as a joint Consensus Statement (2014) and are signatories of a Memorandum of Understanding (2017) in which they commit to ending conversion therapy within their professions. ↩

14. Some of the groups referred to are members of the international coalition of ex-gay organisations called ‘Positive Approaches to Healthy Sexuality’ (formerly called ‘Positive Alternatives to Homosexuality’) ↩

15. It should be noted that some severe mental health conditions may, in rare cases, present in a similar way to gender dysphoria (for example, psychotic disorders can cause delusional beliefs about gender) or cause a lack of sexual interest. However, health professionals should not assume that an asexual or transgender identity is necessarily a symptom of a mental health condition even when they co-exist (Richards and Barker, 2013). ↩

16. By comparison, a YouGov survey (n=5,375) commissioned in 2017 by Stonewall in the UK found 5% of LGBT respondents reported having been pressured to access services to question or change their sexual orientation (Bachmann and Gooch, 2018). ↩

17. The YouGov/Stonewall survey found 20% of transgender respondents reported having been pressured to access services to suppress their gender identity when accessing healthcare services (Bachmann and Gooch, 2018). ↩

18. This survey asked respondents “did any professional (such as a psychologist, counsellor, religious advisor) try to make you identify with your sex assigned at birth (in other words, try to stop you being transgender)?”. ↩

19. Although it did not meet the inclusion criteria for the rapid evidence assessment, a UK-based Faith and Sexuality 2018 survey by the Ozanne Foundation (2019) found that of those respondents who gave reasons for having undergone sexual orientation change efforts, the majority reported it was because they believed their same-sex attractions were sinful (72%), due to feelings of shame associated with their sexual orientation (63%) and because a religious leader disapproved of their sexual orientation (54%). ↩

20. At the 6 year follow up, the client was found to be living as a transgender woman and awaiting gender confirmation surgery. ↩

21. There are a small number of more rigorous early studies that focus on the use of aversion therapy (for example, electric shock and chemically induced nausea). These were generally found to be ineffective at modifying sexual orientation (APA, 2009a). ↩

22. One prospective study cited by some conversion therapy advocates (Jones and Yarhouse, 2007) was identified but did not meet our inclusion criteria as it was published in the grey literature. However, the study was considered in a systematic review (APA, 2009a) that concluded that the study’s claims were unpersuasive due to methodological problems including the absence of a control or comparison group, and deficiencies in the choice of measures and statistical analysis. The authors of the study themselves also acknowledge that their method “fails to meet a number of ideal standards” (p. 408) for studies of this type. ↩

23. A review by the US Substance Misuse and Mental Health Services Administration (2015) also concluded that the existing research does not support the premise that psychological interventions can alter sexual orientation or gender identity. ↩

24. By the mid-1970s there was early clinical evidence that attempts to modify gender identity by psychological means (for example, psychotherapy or aversion therapy) typically failed and that gender reassignment surgery combined with affirmative psychological support more consistently resulted in positive outcomes (Yardley, 1976). There is also more recent evidence that transgender affirmative healthcare is associated with positive outcomes for transgender people (APA, 2009b). ↩

25. This article has been retracted since the start of the current review. It is included here as it is often cited by conversion therapy advocates. ↩

26. See Drescher and Zucker (2006) for a thorough critique of Spitzer’s (2003) study. Other studies cited by conversion therapy advocates (for example, Nicolosi, Byrd, and Potts, 2000b, RETRACTED: Santero, Whitehead and Ballesteros, 2018) share many of the same flaws as Spitzer’s study including biased samples that recruit participants via conversion therapists. ↩

27. Natural fluctuations in sexuality may occur but this is not evidence in itself that that sexual orientation can be deliberately modified by conversion therapies. Furthermore, it is unclear to what extent self-reported sexual fluidity represents changes in sexual orientation or simply changes in how people label their sexual orientation over time. ↩

28. This interviewee described his sexual orientation as ‘same-sex attracted’. ↩

29. These 2 interviewees continued to periodically attend conversion therapy weekend retreats both in the UK and in other countries. One identified his sexual orientation as ‘gay’ and the other as ‘same-sex attracted’ despite having engaged with conversion therapy for a number of years. ↩

30. Early studies that focus on the use of aversive treatments (for example, electric shock and chemically induced nausea) found some participants suffered harmful side effects including depression, suicidality and anxiety (APA, 2009a). However, these findings cannot necessarily be generalised to modern forms of conversion therapies. ↩

31. Information provided as of June 2020. While every effort has been made to ensure this information is accurate and confirmed by primary sources (for example, the laws themselves), in some cases we have needed to rely on secondary sources which may not always be accurate. ↩

32. This list may not be exhaustive and reflects the time at which this research was undertaken. ↩

33. New Jersey Superior Court, Ferguson and others v. JONAH and others: Memorandum of decision, 19 June 2019 ↩

34. PATH has at least 4 UK-based member organisations listed on their website. The life coach fined in Madrid promoted herself as “a Certified Coach in sexual orientation by PATH”. ↩

35. https://www.reintegrativetherapy.com/reintegrative-therapy ↩

36. https://www.core-issues.org/change-oriented-therapy ↩