A systematic review of the prevalence of lifetime experience with 'conversion' practices among sexual and gender minority populations.

RATIONALE: Conversion practices (CPs) refer to organized attempts to deter people from adopting or expressing non-heterosexual identities or gender identities that differ from their gender/sex assigned at birth. Numerous jurisdictions have contemplated or enacted legislative CP bans in recent years. Syntheses of CP prevalence are needed to inform further public health policy and action. OBJECTIVES: To conduct a systematic review describing CP prevalence estimates internationally and exploring heterogeneity across country and socially relevant subgroups. METHODS: We performed literature searches in eight databases (Medline, Embase, PsycInfo, Social Work Abstracts, CINAHL, Web of Science, LGBTQ+ Source, and Proquest Dissertations) and included studies from all jurisdictions, globally, conducted after 2000 with a sampling frame of sexual and gender minority (SGM) people, as well as studies of practitioners seeing SGM patients. We used the Hoy et al. risk of bias tool for prevalence studies and summarized distribution of estimates using median and range. RESULTS: We identified fourteen articles that reported prevalence estimates among SGM populations, and two articles that reported prevalence estimates from studies of mental health practitioners. Prevalence estimates among SGM samples ranged 2%-34% (median: 8.5). Prevalence estimates were greater in studies conducted in the US (median: 13%), compared to Canada (median: 7%), and greater among transgender (median: 12%), compared to cisgender (median: 4%) subsamples. Prevalence estimates were greatest among people assigned male at birth, whether transgender (median: 10%) or cisgender (median: 8%), as compared to people assigned female at birth (medians: 5% among transgender participants, 3% among cisgender participants). Further differences were observed by race (medians: 8% among Indigenous and other racial minorities, 5% among white groups) but not by sexual orientation. CONCLUSIONS: CPs remain prevalent, despite denouncements from professional bodies. Social inequities in CP prevalence signal the need for targeted efforts to protect transgender, Indigenous and racial minority, and assigned-male-at-birth subgroups.

Mapping Community-Engaged Implementation Strategies with Transgender Scientists, Stakeholders, and Trans-Led Community Organizations.

PURPOSE OF REVIEW: Pre-exposure prophylaxis (PrEP) represents one of the most effective methods of prevention for HIV, but remains inequitable, leaving many transgender and nonbinary (trans) individuals unable to benefit from this resource. Deploying community-engaged PrEP implementation strategies for trans populations will be crucial for ending the HIV epidemic. RECENT FINDINGS: While most PrEP studies have progressed in addressing pertinent research questions about gender-affirming care and PrEP at the biomedical and clinical levels, research on how to best implement gender-affirming PrEP systems at the social, community, and structural levels remains outstanding. The science of community-engaged implementation to build gender-affirming PrEP systems must be more fully developed. Most published PrEP studies with trans people report on outcomes rather than processes, leaving out important lessons learned about how to design, integrate, and implement PrEP in tandem with gender-affirming care. The expertise of trans scientists, stakeholders, and trans-led community organizations is essential to building gender-affirming PrEP systems.

Sexual Orientation and Gender Identity and Expression Change Efforts and Suicidality: Evidence, Challenges, and Future Research Directions.

Sexual orientation and gender identity and expression change efforts (SOGIECE) aim to deny or suppress nonheterosexual and transgender identities. SOGIECE, including "conversion practices," are controversial and remain prevalent despite contemporary legislative bans and denouncement of these harmful practices from numerous health profession organizations. Recent work has questioned the validity of epidemiological studies associating SOGIECE with suicidal thoughts and suicide attempts. This perspective article addresses such critiques, arguing that the balance of available evidence indicates SOGIECE contribute to suicidality, while proposing methods to better account for structural context and the multitude of factors that may explain both SOGIECE attendance and suicidality.

Youth should decide: the principle of subsidiarity in paediatric transgender healthcare.

Drawing on the principle of subsidiarity, this article develops a framework for allocating medical decision-making authority in the absence of capacity to consent and argues that decisional authority in paediatric transgender healthcare should generally lie in the patient. Regardless of patients' capacity, there is usually nobody better positioned to make medical decisions that go to the heart of a patient's identity than the patients themselves. Under the principle of subsidiarity, decisional authority should only be held by a higher level decision-maker, such as parents or judges, if lower level decision-makers are incapable of satisfactorily addressing the issue even with support and the higher level decision-maker is better positioned to satisfactorily address the issue than all lower level decision-makers. Because gender uniquely pertains to personal identity and self-realisation, parents and judges are rarely better positioned to make complex medical decisions. Instead of taking away trans youth's authority over their healthcare decisions, we should focus on supporting their ability to take the best possible decision for themselves.

Interrogating Gender-Exploratory Therapy.

Opposition to gender-affirmative approaches to care for transgender youths by some clinicians has recently begun to consolidate around "gender exploratory therapy" as a proposed alternative. Whereas gender-affirmative approaches follow the client's lead when it comes to gender, gender-exploratory therapy discourages gender affirmation in favor of exploring through talk therapy the potential pathological roots of youths' trans identities or gender dysphoria. Few detailed descriptions of the approach's parameters have been offered. In this article, I invite clinicians to reflect on gender-exploratory therapy through a series of questions. The questions are followed by an exploration of the strong conceptual and narrative similarities between gender-exploratory therapy and conversion practices. Finally, the ethical dimensions of gender-exploratory therapy are discussed from the lenses of therapeutic neutrality, patient-centered care, loving attention, and therapeutic alliance, suggesting that the approach may be unethical.

Transporting the Burden of Justification: The Unethicality of Transgender Conversion Practices.

Transgender conversion practices involve attempts to alter, discourage, or suppress a person's gender identity and/or desired gender presentation, including by delaying or preventing gender transition. Proponents of the practices have argued that they should be allowed until proven to be harmful. Drawing on the notion of expressive equality, I argue that conversion practices are prima facie unethical because they do not fulfill a legitimate clinical purpose and conflict with the self-understanding of trans communities.

Adolescent Medical Transition is Ethical: An Analogy with Reproductive Health.

In this article, I argue that adolescent medical transition is ethical by analogizing it to abortion and birth control. The interventions are similar insofar as they intervene on healthy physiological states by reason of the person's fundamental self-conception and desired life, and their effectiveness is defined by their ability to achieve patients' embodiment goals. Since the evidence of mental health benefits is comparable between adolescent medical transition, abortion, and birth control, disallowing transition-related interventions would betray an unacceptable double standard. While great enough risks can override autonomy over fundamental aspects of personal identity, I demonstrate that the available scientific evidence does not corroborate the view that adolescent medical transition is dangerous. Consequently, adolescent medical transition should be recognized as ethical and remain available.

Health Care Experiences of Patients Discontinuing or Reversing Prior Gender-Affirming Treatments.

Importance: Medical education, research, and clinical guidelines are available to support the initiation of gender-affirming care for transgender and nonbinary people. By contrast, little is known about the clinical experiences of those who discontinue or seek to reverse gender-affirming medical or surgical interventions due to a change in gender identity, often referred to as detransition. Objective: To examine the physical and mental health experiences of people who initiated medical or surgical detransition to inform clinical practice. Design, Setting, and Participants: Using constructivist grounded theory as a qualitative approach, data were collected in the form of in-depth interviews. Data were analyzed using an inductive 2-stage coding process to categorize and interpret detransition-related health care experiences to inform clinical practice. Between October 2021 and January 2022, individuals living in Canada who were aged 18 years and older with experience of stopping, shifting, or reversing a gender transition were invited to partake in semistructured virtual interviews. Study advertisements were circulated over social media, to clinicians, and within participants' social networks. A purposive sample of 28 participants who discontinued, shifted, or reversed a gender transition were interviewed. Main Outcomes and Measures: In-depth, narrative descriptions of the physical and mental health experiences of people who discontinued or sought to reverse prior gender-affirming medical and/or surgical interventions. Results: Among the 28 participants, 18 (64%) were assigned female at birth and 10 (36%) were assigned male at birth; 2 (7%) identified as Jewish and White, 5 (18%) identified as having mixed race and ethnicity (which included Arab, Black, Indigenous, Latinx, and South Asian), and 21 (75%) identified as White. Participants initially sought gender-affirmation at a wide range of ages (15 [56%] were between ages 18 and 24 years). Detransition occurred for various reasons, such as an evolving understanding of gender identity or health concerns. Participants reported divergent perspectives about their past gender-affirming medical or surgical treatments. Some participants felt regrets, but a majority were pleased with the results of gender-affirming medical or surgical treatments. Medical detransition was often experienced as physically and psychologically challenging, yet health care avoidance was common. Participants described experiencing stigma and interacting with clinicians who were unprepared to meet their detransition-related medical needs. Conclusions and Relevance: This study's results suggest that further research and clinical guidance is required to address the unmet needs of this population who discontinue or seek to reverse prior gender-affirming interventions.

Sexual orientation and gender identity and expression conversion exposure and their correlates among LGBTQI2+ persons in Québec, Canada.

BACKGROUND: Despite greater acceptance of sexual and gender diversity and the scientific consensus that same-gender attraction, creative gender expression, and transness are not mental illnesses, LGBTQI2+ persons are still commonly told that they can or should change their sexual orientation, gender identity, or gender expression (SOGIE). The aim of this study was to describe the prevalence of SOGIE conversion efforts, including their sociodemographic correlates, among LGBTQI2+ persons. METHODS: Using community-based sampling, we assessed SOGIE conversion attempts and involvement in conversion services of 3,261 LGBTQI2+ persons aged 18 years and older in Quebec, Canada. RESULTS: A quarter of respondents experienced SOGIE conversion attempts, and fewer than 5% were involved in conversion services. Over half of those who were involved in SOGIE conversion services consented to them, but the services' goals were made clear and explicit to only 55% and 30% of those who engaged in SO and GIE conversion, respectively. The results also suggest that family plays a key role in SOGIE conversion attempts and services utilization, and that indigenous, intersex, transgender, non-binary, and asexual persons, people of colour, as well as individuals whose sexual orientation is not monosexual (i.e., bisexual, pansexual) were more likely to have been exposed to conversion attempts and involved in conversion services. CONCLUSIONS: This study found that the prevalence of conversion efforts is substantial. Interventions to protect LGBTQI2+ people from such attempts should focus not only on legal bans, but also on supporting families who need to be counseled in accepting sexual and gender diversity. Health professionals need to be adequately trained in LGBTQI2+ affirmative approaches. Religious therapists should consult with colleagues and undergo supervision to ensure that their religious beliefs do not interfere with their practice.

Transgender data collection in the electronic health record: Current concepts and issues.

There are over 1 million transgender people living in the United States, and 33% report negative experiences with a healthcare provider, many of which are connected to data representation in electronic health records (EHRs). We present recommendations and common pitfalls involving sex- and gender-related data collection in EHRs. Our recommendations leverage the needs of patients, medical providers, and researchers to optimize both individual patient experiences and the efficacy and reproducibility of EHR population-based studies. We also briefly discuss adequate additions to the EHR considering name and pronoun usage. We add the disclaimer that these questions are more complex than commonly assumed. We conclude that collaborations between local transgender and gender-diverse persons and medical providers as well as open inclusion of transgender and gender-diverse individuals on terminology and standards boards is crucial to shifting the paradigm in transgender and gender-diverse health.

Flawed reasoning on two dilemmas: a commentary on Baron and Dierckxsens (2021).

A recent paper by Teresa Baron and Geoffrey Dierckxsens (2021) argues that puberty blockers and hormone therapy should be disallowed before adulthood on prudential and consent-related grounds. This response contends that their argument fails because it is predicated on unsupported premises and misinterpretations of the available evidence. There is no evidence that a large proportion of pubertal and postpubertal youths later discontinue medical transition. Meaningful assent is a viable and commonly accepted alternative to meaningful consent in paediatric bioethics. And finally, the primary purpose of transition-related interventions is to actualise youths' gendered self-image, not treat an underlying mental illness.

The scope and nature of sexual orientation and gender identity and expression change efforts: a systematic review protocol.

BACKGROUND: Sexual orientation and gender identity and expression change efforts (SOGIECE) are a set of scientifically discredited practices that aim to deny and suppress the sexual orientations, gender identities, and/or gender expressions of sexual and gender minorities (SGM). SOGIECE are associated with significant adverse health and social outcomes. SOGIECE continue to be practiced around the world, despite denouncements from professional bodies and survivors, as well as calls for legislative advocacy to prohibit SOGIECE and protect SGM. There are substantial gaps in the availability of consolidated international research to support and refine legislative proposals related to SOGIECE, including those currently underway to enforce bans in Canada and elsewhere. We therefore propose the first systematic review of international data on SOGIECE that will outline the scope and nature of these practices worldwide. Specifically, we aim to estimate how many SGM have been exposed to SOGIECE, which sub-groups of SGM experience higher rates of SOGIECE, and how estimates of SOGIECE vary over time and place. In addition, we aim to describe when, where, how, and under what circumstances SGM are exposed to SOGIECE. METHODS: To locate an interdisciplinary swath of papers, nine (9) bibliographic databases will be searched: Medline (OVID), Embase (OVID), PsycInfo and Social Work Abstracts via EBSCO, CINAHL, Web of Science Core Collection, LGBTQ+ Source, and Proquest Dissertations & Theses Global and Sociology Collection (ProQuest). A gold standard search will be developed for Medline and adapted to the other databases. Grey literature will be searched at relevant websites, and reference harvesting will be performed in relevant SOGIECE scientific consensus statements. Two authors will independently screen abstracts/titles, screen full texts, abstract data, and apply risk of bias assessments. A narrative synthesis will be implemented to summarize findings. DISCUSSION: This review will address the gap in synthesized data regarding the prevalence of SOGIECE, social correlates of SOGIECE, variations of SOGIECE over time and place, and the circumstances, settings, and time-points of SOGIECE exposure. Findings from this review will directly inform ongoing and new legislative efforts to ban SOGIECE and other interventions that aim to stem SOGIECE practices and support SOGIECE survivors. SYSTEMATIC REVIEW REGISTRATION: Registration with PROSPERO can be found under the registration number: CRD42020196393 .

The Misuse of Gender Dysphoria: Toward Greater Conceptual Clarity in Transgender Health.

The notion of gender dysphoria is central to transgender health care but is inconsistently used in the clinical literature. Clinicians who work in transgender health must understand the difference between the diagnosis of Gender Dysphoria as defined and described in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders and the notion of this term as used to assess eligibility for transition-related interventions such as hormone-replacement therapy and surgery. Unnecessary diagnoses due to the belief that a diagnosis is clinically required to access transition-related care can contribute to stigma and discrimination toward trans individuals.

Accounting for research fatigue in research ethics.

How to account for participants' psychological and emotional exhaustion with research has been under-explored in the research ethics literature. Research fatigue, as it is known, has significant impacts on patients' well-being and their ongoing and future participation in studies. From the perspective of researchers and researched communities, research fatigue also creates selection bias and opportunity costs, negatively impacting the collective scientific enterprise. Institutional Review Boards should systematically consider research fatigue during the research approval process and strive to mitigate it.