Conversion Therapy, Suicidality, and Running Away: An Analysis of Transgender Youth in the U.S.

Transgender individuals in the U.S. still face widespread stigma, discrimination, and violence (Winter, 2016; Carpenter, 2020). Problems of stigma and discrimination can lead to poor physical and mental health outcomes, and gender minority stress and gender dysphoria lie at the root of these inequities (Meyer, 2003; Turban, 2022). A major problem is the lack of family acceptance and support, which directly contributes to stress and dysphoria and also acts as a block against access to insurance and health care. In fact, Kundu et al. (2022) find that being insulted by one's parents or an adult during childhood ranks among the top three correlates of suicidal thoughts in the past year among a sample of sexual and gender minority young adults in Canada. Hostile parents, in turn, often encourage or coerce their transgender children into undergoing sexual orientation or gender identity change efforts, often referred to as “conversion therapy” or “conversion practices.”1 These efforts, usually led by counselors or religious advisors, aim to change an individual's sexual orientation or to discourage individuals, especially adolescents, from identifying as transgender or from expressing themselves in gender-diverse ways.

Most professional associations related to mental health and the health of young people have critiqued conversion therapy as being ineffective at best and harmful at worst, and 20 states have banned the practice (Mallory, 2019; MAP, 2022). However, there is very little quantitative evidence on the effects of conversion therapy on measures of mental health and wellbeing among trans and gender-diverse youth. Although quite a few studies across disciplines have been published on conversion therapy (e.g. James, 2016; Turban, 2020; Higbee 2022), to our knowledge, none of them address important sources of selection into conversion therapy as explained below.

Our goal is to fill this gap by using data from the 2015 U.S. Transgender Survey (USTS) to examine the relationship between conversion therapy and the risk of attempting suicide and running away for transgender adolescents. Since unobservable characteristics such as socioeconomic status and upbringing may affect both conversion therapy exposure and measures of wellbeing, simple correlations that do not account for differences in characteristics between the treated and control groups prior to conversion therapy exposure may be misleading, and they cannot prove that young people who are subjected to conversion therapy are at a greater risk of poor wellbeing because of the therapy. For example, trans youth exposed to conversion therapy may have had other disadvantages (such as living in a hostile community or having lower socioeconomic status) that could explain both the conversion therapy participation and the poor wellbeing, or they may have had poor wellbeing that led their parents to consider conversion therapy. To identify the effect of conversion therapy on measures of wellbeing, we utilize a difference-in-differences (DID) approach. This approach allows us to estimate a substantive treatment effect of conversion therapy on the risk of attempting suicide and running away for transgender adolescents.

By comparing transgender adolescents who are exposed to conversion therapy (treated group) with those who are either never exposed or are exposed later on (control group), we find that conversion therapy increases the risk of attempting suicide by 17 percentage points, which amounts to a 55% increase in the risk of attempting suicide, and running away by 7.8 percentage points, more than doubling the risk of running away. The effects are largest when exposure to conversion therapy occurs at a young age (11-14). These estimates are compelling not only because they pass a battery of falsification and robustness tests, but also because the rate of attempting suicide and running away is remarkably similar in both level and trend between the treated and control groups over the five years preceding conversion therapy. Furthermore and most importantly, the estimates hold when we exploit only the precise timing of conversion therapy, limiting the control group to those who are exposed to conversion therapy one year after the treated group.

Our paper contributes to the literature on transgender well-being. Numerous studies have shown that transgender individuals are more likely to report poor general, physical, and mental health compared to their cisgender counterparts (Meyer, 2017; Cicero, 2020; Campbell and Rodgers, 2022). Mental health disparities are particularly stark, with considerably higher rates of depression, anxiety, PTSD, suicidality, and substance abuse in the U.S. transgender community (Haas, 2014; Marshall, 2016; Reisner, 2016, Downing, 2018; Lagos, 2018). Data from the USTS indicate that 40% of respondents had attempted suicide at least once in their lifetime, a rate that exceeds that of the general population by a factor of close to nine (James, 2016). Moreover, in a 2017 survey of U.S. high school students, 34.6% of the transgender students had attempted suicide compared to 5.5% of cisgender male students and 9.1% of cisgender female students (Johns, 2019). These kinds of mental health disparities also have repercussions for the labor market, with losses in human capital and labor productivity (e.g. Lerner and Henke 2008; Chatterji et al. 2011; Rivera et al. 2017; Dow et al. 2020).

For both indicators we examine, risk factors include depression, lack of family and community support, and victimization (Thompson, 2006). Although the magnitude of welfare losses seems at least an order of magnitude larger for suicide attempts compared to running away, we argue that running away is an important indicator of wellbeing because this action increases the subsequent risk of drug addiction, homelessness, sexual risk taking, dropping out of school, criminal activity, and additional depressive symptoms (Kaufman and Widom, 1999; Tucker, 2011; Rice et al,. 2013; Aratani and Cooper 2015).

This study also offers timely evidence to inform the discussion of public policies relating to transgender health. Although a number of states have institutionalized bias against transgender individual (with, for example, provisions that exclude gender-affirming care from Medicaid coverage), several states have introduced such gender affirming policies as conversion therapy bans as well as gender marker laws that allow people to change their gender on official documents such as birth certificates and drivers licenses (Mann, 2021). These policy changes have placed transgender issues in the national spotlight and increased the need for empirical evidence on their possible welfare effects. However, relatively little is known about the effect of either affirming or exclusionary laws, given a relative dearth of data that allow the identification of transgender individuals. By using the U.S. Transgender Survey – the largest survey of transgender individuals of its kind – and recently-developed estimation techniques, this study aims to contribute new evidence on welfare outcomes associated with conversion therapy that should help to inform these policy discussions.

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