Better understanding of the scope and nature of LGBTQA+ religious conversion practices will support recovery

Both formal and informal conversion practices can be traumatic for LGBTQA+ people who are exposed to them

Australian states and territories have recently moved to ban practices aimed at changing or supressing the sexuality or gender identity of lesbian, gay, bisexual, transgender, queer, asexual or gender and sexually diverse (LGBTQA+) people, often referred to as “conversion practices” (Box 1).1,2,3,4,5 This legislative trend mirrors global recognition of the harms caused by conversion practices (Box 1)6,7,8,9 and is supported by the 2021 Australian Medical Association’s position statement on LGBTQIA+ health, which calls on state and territory governments to “ban coercive ‘conversion’ practices”.10 The Australian Psychological Society11 and the Royal Australian and New Zealand College of Psychiatrists12 have also issued position statements stating that sexual or gender orientation change efforts of any kind are harmful and are not supported by these organisations. While it is difficult to estimate the number of people affected by conversion practices in Australia, international research has suggested that up to 14% of people who identify as LGBTQA+ have had some exposure to conversion practices.13

Recent research has shown that conversion practices are poorly understood in Australia and that health workers would benefit from training to improve their care of survivors.14

One reason for confusion relates to unclear definitions of conversion practices. Until recently, it was common to refer to such practices as “conversion therapy” or “reparative therapy”. The term “therapy” implies formal therapeutic practices or interventions. This is one form of conversion practices, which may involve cognitive behavioural therapy, psychoanalytic treatment based on beliefs that homosexuality or gender diversity is the result of a disordered upbringing, aversion therapy aimed at cognitive or sensory retraining, hormonal therapy or use of natural medicines aimed at altering sexual attractions, structured faith‐based programs that use prayer, or group‐based treatment similar to 12‐step programs (Box 2).9,17,18 Although less common in Australia, formal conversion practices may take place in institutional settings, including counselling rooms; clinics, hospitals9 or community facilities; faith settings, such as churches and mosques; and in homes. Religious, medical or mental health practitioners may be involved in these forms of conversion therapy.9,17

For people unfamiliar with conversion practices, formal interventions such as those described above are often imagined to constitute the majority of interventions. In part, this is because film or television depictions of conversion practices often involve medical treatment or counselling programs reminiscent of 1960s‐style psychological aversion therapy.14 However, in Australia, conversion practices are most often unstructured and informal.14,19 This may include LGBTQA+ people being repeatedly told by friends, family or faith leaders and communities that they are in some way damaged but can be helped, fixed or saved. It may also involve informal discussions or pastoral care meetings set up to teach, encourage or support LGBTQA+ people to change or suppress their sexuality or gender identity or to conceal their gender. Examples of formal and informal conversion practices are presented in Box 2.14,15,19,20 For people who identify as asexual, conversion practices may involve pressure to express heterosexual attraction or pursue conventional heterosexual marriage.14

In response, many LGBTQA+ people seek out or initiate conversion practices of their own accord.14 Almost always, these efforts are underpinned by promotion of ideologies that position non‐heterosexual or gender diverse identities or attractions as the product of damage, neglect, deviance or undesirable social or spiritual influence (sometimes referred to as “sexual brokenness”).15 LGBTQA+ people have often received the message that their sexuality or gender identity is unacceptable, that they are failing themselves, their family or faith, and that they may be rejected by their family or community if they cannot identify the source of their brokenness, be healed, or change.14,16,18,19

Both formal and informal conversion practices can be highly traumatic for LGBTQA+ people who are exposed to them.14,19 Survivors may experience complex trauma or post‐traumatic stress disorder and many report poor mental health, suicidality and ongoing feelings of shame, grief and loss.13,20 There is no evidence that conversion practices in any form are effective at changing sexuality or gender identity,9,12,18,20 although they may convince some people to conceal their sexuality or gender identity, which can contribute to further mental health harms.17

Lack of general awareness about the informal nature of most conversion practices can make it difficult for survivors to access appropriate medical or psychological care. Many LGBTQA+ people assume conversion practices involve formal therapy. As such, survivors themselves may not recognise, or have language to explain, their experiences. Mental health practitioners, or general practitioners conducting mental health assessments, may similarly find it difficult to recognise informal conversion practices as significant or related to a patient’s presenting symptoms of trauma.14,20 Recent Australian research has also indicated that practitioners may not routinely include questions about religion in patient or client assessments and may not feel comfortable asking patients and clients about their religious background. This may be a further barrier for survivors in accessing support.14

When patients and clients disclose experiences of conversion practices, they should be supported to seek trauma‐informed mental health services and support for grief and loss, which may be associated with loss of family, community or spirituality.14,21 It is important for practitioners to validate sexual and gender diversity alongside spirituality and religion, as many survivors struggle to reconcile these two aspects of their life and identity in ways that do not undermine their sense of self or connection to others.14,21 This approach is affirmed by the Royal Australian and New Zealand College of Psychiatrists’ position statement Sexual orientation change efforts, which states:

With respect to legislative responses, the informal nature of many conversion practices, and the fact that survivors may have self‐initiated some aspects of their conversion experiences, means a ban based on penalties for people delivering therapy may not adequately address the problem.16 Legislative and regulatory responses to conversion practices will therefore be most effective if they are enacted alongside a comprehensive civil response. Such responses may include investment in public education and peer‐based support, along with mechanisms to investigate and respond to complaints or allegations of conversion practices outside of the criminal system in ways that are appropriate for affected survivors.14,16

As part of a comprehensive civil response, training for medical and mental health practitioners will be important given that increased public attention on these issues will likely lead more survivors to seek support. It is significant that the Australian Medical Association, the Australian Psychological Society and the Royal Australian and New Zealand College of Psychiatrists have issued statements against conversion practices. These could be further supported by provision of more information for members about the scope and nature of conversion practices and ideology, details of appropriate referral pathways, and support for training.

Conversion practices, both formal and informal, cause significant mental health harms. As evidence and understanding of these harms increase and governments enact responses, there is a need for the health sector to be engaged with these issues so that practitioners are appropriately prepared to recognise, support and respect survivors in ways that are affirming of sexual and gender diversity.