1.1. Framing conversion practices

The field’s evolution was founded within western psychological epistemologies that pathologised same sex attraction and resulted in the adoption of a deficit-reparative focus which explored the efficacy of “conversion”, “reparative” or “reorientation” therapies [5]. Reparative “therapeutic” methods ranged from psychotherapeutic interventions, including hypnosis and psychoanalytic techniques [6, 7]; behavioural therapeutic methods including masturbatory reconditioning and aversion therapy [8–10] abstinence training and teaching traditional gender roles [6, 7], and biological methods, such as medication, electroconvulsive therapy, surgery (castration, lobotomy, and the removal of ovaries), and hormone therapy [7, 11, 12].

In 1973, growing concern over the harms associated with conversion therapy, and especially driven by gay liberation activists [13], culminated in the American Psychological Association’s removal of homosexuality from the Diagnostic and Statistical Manual of Mental Disorders; a move that signalled a significant epistemological shift unseating the psychological legitimacy of reparative therapy [14].

Western psychology’s gradual movement away from a reparative focus coincided with the increasing influence of the religious conversion therapy movement [15]. These therapies have persisted, justified by theological arguments that position sexual orientation, gender identity, and gender expression that fall outside of religious dictates of heteronormativity as moral transgressions and supported by proponents’ claims that the combination of faith and the use reparative psychotherapeutic interventions can realign the individual to fit heteronormative ideals [1, 2].

Within this context, a singular focus on conversion therapy failed to encompass survivors’ varied experiences and limited the extent to which survivors’ experiences can be understood. In response, some studies broadened conversion-related conceptualisations to include conversion practices that acknowledge the existence and impact of formal conversion practices, generally regarded as synonymous with conversion therapy and inclusive of reparative “therapeutic” methods, and informal conversion practices which acknowledge the existence and associated harms of informal change efforts, inclusive of negative change messaging from friends, family, faith leaders, and community members [2]. Significantly, more recently, a small number of conversion practice-centred studies have included conversion ideology to umbrella conversion practices within heteronormative and cisgender discourses, manifesting as overt spoken beliefs and teachings, and the underlying culture of a particular community of people, that stress the ‘brokenness’ of those with non-conforming gender and sexual identities while simultaneously asserting that spiritual or psychological interventions can “heal” an individual [2, 16].

Parallel to the use of conversion practices, a growing number of researchers have referred to ‘sexual orientation and gender identity or expression change efforts’ (SOGIECE). However, the use of SOGIECE lacks clear definitional parameters and, consequently, research findings are not comparable. Some studies have treated sexual orientation change efforts (SOCE) as synonymous to conversion or reparative therapy [1, 5, 17, 18]. Others have treated SOGIECE synonymously with informal conversion practices and the impact of institutional cisgender heteronormative dictates [19] whereas others invoke SOGIECE to include conversion practices and conversion ideology [20]. Finally, some SOGIECE-related studies have included change efforts external to faith-based contexts, a development that is important and reinforces the need for conceptual consensus [1].

To reduce definitional ambiguity the current study is framed in accordance with faith-based conversion practice conceptualisations, inclusive of conversion ideology and formal and informal conversion practices.

1.2. Conversion practices research

The advent of the religious conversion therapy movement coincided with three primary tranches of emancipatory-centred studies that aimed to provide an evidence base to support the eradication of conversion practices. The first research tranche focused on harms arising from efforts to change someone’s sexual orientation, gender identity or expression. Identified harms have included fear and shame [21], anxiety [22], depression [21–23], negative self-esteem [21], suicidality [1, 3, 17, 21, 23, 24], non-suicidal self-injury [1, 3, 22], and self-hatred [21–23, 25], as well as internalised homonegativity [21, 23], sexual dysfunction [21], decreased capacity for same-sex intimacy [23], significant harm to interpersonal relationships and social functioning [21, 23] and spiritual harm, inclusive of a loss of faith and spirituality [21, 23, 25].

A second tranche of research has focused on conversion practice prevalence [1, 3, 17, 19, 24, 26–31]. The majority of prevalence surveys to date have been conducted in the United States and have included adult populations. Using a phone survey, Blosnich et al. [17] estimated that 7% of transgender adults had experienced any conversion therapy, while James and colleagues [26], using an online survey, estimated that 14% of transgender adults had experienced conversion therapy from family members. An online survey of LGBTIQ+ youth conducted by Green et al. [24] reported that 4.2% had experienced conversion therapy. Meanley et al. [28] reported that 17.7% of middle-aged and older men who have sex with men, who were included in the US multicentre AIDS cohort study, had experienced conversion therapy.

There are wide variations in prevalence estimates from investigations conducted in Aotearoa New Zealand. An online survey of gender and sexual diverse youth estimated that 3.7% had experienced conversion therapy [1]. In contrast, Veale et al. [3] estimated that 19.7% of trans and non-binary adults aged 14 years and over had experienced conversion therapy. Differences in prevalence estimates are likely to be due to the age of the population sampled, with older populations having increased opportunity for experience, the gender or sexual orientation of participants, recruitment methods, and community context. For example, a face-to-face survey conducted by Ryan and colleagues in the United States, recruiting youth participants from bars and clubs [30] found that over 50% of their participants had experienced conversion therapy from family members, and around half of these had also experienced more formal conversion therapy. Notably, reliable prevalence data has been difficult to access for lesbian or bisexual cisgender women as gender has not been disaggregated from cisgender male experiences [24].

A third, and most recent, tranche of research has explored what has helped survivors in their recovery. In general, commentary has centred on therapeutic support interventions and have either documented mental health professionals’ experiences in working alongside survivors and how these experiences can inform clinical practice [14, 32], or have involved phenomenological investigations into survivors’ experiences with therapy, with a particular focus on how mental health professionals should align practice to the lived experiences and needs of survivors [22, 23, 33].

In light of the scant evidence available to mental health professionals, Jones et al. [20] carried out a qualitative study of survivors in Australia to better understand survivor recovery pathways. The authors found that post-conversion practice recovery was more successful if survivors experience three provisions: people who are affirming, enabling them to freely be themselves–especially health and mental health practitioners, family and friends, and survivor support groups; considerable time and internal motivation to enable support to be effective; and conflicting aspects of identities and beliefs are reconciled in ways that foreground survivors’ autonomy in their reconstruction. Despite the use of an ecological model to frame the research, the study’s strong mental health focus, in general, restricted recovery experiences within the purview of mental health professionals and not wider support mechanisms, either in the short or longer-term.

1.3. The current study

Conversion practices research has generally adopted an emancipatory focus by documenting harms, prevalence or informing appropriate therapeutic approaches to support survivors. Little attention has focused on what is required to support survivors, external to mental health responses, inclusive of current, past, and potential exposure to conversion practices. The current study seeks to understand holistic survivor-centric intervention opportunities and support needs. Notably, no support-focused research has been undertaken in nations after the criminalisation of conversion practices, and the Aotearoa New Zealand context provides an opportunity to understand survivor needs in a context of legislated protection.

2.1. Recruitment

Ethics approval for this study was granted by Aotearoa Research Ethics Committee (approval number: AREC23_04). Participants were recruited using purposive sampling between 10 March and 28 April 2023. The New Zealand Human Rights Commission commissioned the study and promoted the research through social media posts, radio, and sharing study-related information through its survivor networks. In addition, research team members shared an invitation to participate through their networks. Participants were eligible to take part if aged 18 years and over and if they identified as a conversion practice survivor, inclusive of clinical and faith-based settings. If interested, potential participants were invited to contact MR who provided an information sheet, consent form, and biographies of four interviewers that participants were invited to select to carry out the interview. Participants were also informed about the availability of post-interview psychological support. Best efforts were made to provide a range of interviewers according to gender (cisgender, transgender, and non-binary), sexuality (gay, lesbian, gender queer, and takatāpui), age (between 40 and 72 years), ethnicity (Māori and New Zealand European), and whether the interviewer identified as a survivor. Written consent to participate in the study was obtained from all participants (see Table 1 for a glossary Māori translations).

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Table 1. Glossary.

https://doi.org/10.1371/journal.pone.0302163.t001

2.2. Participants

Twenty-five people participated in the interviews. Of these 23 people reported experiencing religious conversion practices across a range of Christian denominations, such as Anglican, Brethren, Roman Catholic, and Pentecostal, as well as independent communities of faith. The remaining two participants were not included in this study and their narrative will be included in a separate paper on non-religious conversion practice experiences.

Participants’ ages ranged between 24 and 72 years, with a median age of 34. Most participants identified as New Zealand European / European (n = 15) with the remaining participants identifying as Asian or Southeast Asian (n = 4), Māori (n = 2) or Pasifika (n = 2).

Cis males were overrepresented in the sample (n = 13). The remaining participants identified as transgender (n = 3), cis female (n = 3), non-binary (n = 3), and gender queer (n = 1). In addition, one participant reported being born with a variation of sex characteristics but did not identify as intersex, describing themselves as transgender. The majority of participants identified as gay (n = 8) with remaining participants identifying their sexuality as bisexual (n = 4), lesbian (n = 3), pansexual (n = 2), gender queer (n = 2), cisgender takatāpui (n = 2). Two participants stated that they did not have a sexuality.

Approximately three quarters (n = 18) of the participants had experienced formal conversion practices. Practices included aversion therapy, counselling through licensed counsellors endorsed by the faith setting or via members of the faith setting who were not formally trained in counselling, medicalisation by physicians endorsed by the faith setting, chemical castration, and through attendance at a variety of multiple-week group conversion sessions derived from US ‘therapeutic’ interventions, such as exorcism or deliverance within a therapeutic setting, and counselling, characterised by a formalised structure and accompanied by individually guided workbooks. Occurring parallel to these processes were a range of mechanisms that repeatedly othered the individual within the faith community, inclusive of public confessions of sin, being sent overseas, and threats of excommunication and punishment of the individual’s family.

The majority of participants first engaged in formal conversion practices in their mid- to late teens; generally occurring before leaving home. Significantly, one participant first engaged in formal conversion therapy at seven years of age, one at 12, and two at 14 years. A minority of participants first engaged in formal conversion practices after leaving home and had either attended Bible college or had accepted leadership roles in a faith setting outside of their town or city of origin. For these participants, encouragement to engage in formal conversion practices occurred because their social network was predominantly or exclusively people who adopted literal biblical heteronormative perspectives regarding sexuality and gender. One participant engaged in conversion practices after they attended university, despite members of their social network urging them to desist.

Some participants engaged in formal conversion practices for a few weeks, others described being in therapy for several years. Some survivors described consecutive involvement in formal conversion practices whereas others described episodic engagement over a period of months and then shifting to informal practices only to return to more formal practices later. In these situations, some years would pass before the individual would reengage in formal conversion practices.

All participants experienced informal conversion practices (n = 23). These practices included prayer, pressure from peers, group deliverance within a congregational context, and non-therapeutic pastoral mentoring that was indirectly associated with negative change messaging, such as engaging in “gender appropriate” activities. Notably, all participants had experienced variations of conversion ideology.

2.3. Data collection

Due to the ongoing impact of COVID-19, individual interviews were conducted online by one of four research team members in the second quarter of 2023.

Interviews followed a semi-structured format that was accompanied by a visual prompt that had been designed in collaboration with a survivor-led advisory group to elicit holistic responses (see Fig 1). The visual prompt positioned the survivor in the centre of five concentric circles. Emanating outwards were whānau (partner, children, chosen family, friends, hapū, extended family), community (Iwi, hapori, culture, faith, recreation, volunteering), society (Aotearoa, government, online spaces, workplaces). The final circle positioned, hauora tinana (physical health), hauora wairua (spiritual health), and hauora hinengaro (mental health) as equidistant.

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Fig 1. Visual interview prompt.

https://doi.org/10.1371/journal.pone.0302163.g001

Interviews began by participants being asked a series of demographic questions (age, gender, sexual orientation, and whether the individual had been born with a variation of sex characteristics). Participants were then asked about their conversion practice experiences, impacts, what has helped, obstacles to the individual’s recovery, the kind of support that would have been useful when the individual first decided to reject conversion practices, the type of support the individual currently needs, and what needs to be done in terms of policy, legislation, and societal attitudes.

The interviews ranged between 60 and 90 minutes and were audio recorded and transcribed with participant consent. Participants received a $50 koha (gift) at the interview’s conclusion, in recognition of their time commitment.

2.4. Data analysis

A discursive approach underpinned transcript analysis. As described by Fairclough [37], this process involved developing emergent themes focused on the presence and interplay of ubiquitous discourses. The process involved attending to the participants’ context, focusing on the language participants used to describe their experiences, and centring on the emergent discursive concepts. Emerging discourses were consistently examined to determine the extent to which they were common across participants. In practice, this meant that discursive positions were created within an analysis framework. The analysis was initially conducted by MR and then refined further by NA. Complementing life history and empowerment methodology the analysis draws heavily on deidentified verbatim quotes that illustrate the emergent discourses.

3.1. Discursive context—contextualising experiences of trauma and healing

A common impediment to participants’ healing journeys was a minimisation of the insidiousness of conversion practices and the pervasive impacts of conversion practice trauma. Minimisation occurred across multiple societal levels, inclusive of faith-based environments, helping professionals, and post-conversion practice social networks, and was compounded by non-survivors’ lack of knowledge about the complex dynamics underpinning conversion practices, and assumptions that such dynamics are a natural consequence of membership in a faith community. Above all, participants stressed that minimisation occurs because of a failure to appropriately frame conversion practices as spiritual abuse.

Multiple participants reinforced the need to elevate conversion practices to the level of spiritual abuse and invoked similarities between the dynamics of family violence and conversion practices. Whilst family violence literature frames perpetration of violence within coercive power dynamics [38], participants described spiritual abuse as a form of coercive control enacted by those in a position of power within, and associated with, a faith-based setting, whether formal, such as conventional faith settings, or informal faith-based collectives. The mechanics of spiritual abuse include the use of faith-based teachings, threats, and demonisation to coerce and cause harm to the individual. Significantly, spiritual abuse can include the use of emotional, financial, physical, psychological, medical, and sexual abuse and these were common across the contexts in which participants experienced conversion practices.

Similarities also emerged between participants’ varied accounts of being “trapped” and the need to locate coercive control within a broader understanding of entrapment [38, 39]. Tolmie et al. [39] describe intimate partner violence operating as a form of social entrapment which comprises three dimensions: social isolation, fear and coercion that the perpetrator’s coercive and controlling behaviour creates in the survivor’s life; the indifference of powerful institutions to the survivor’s suffering; and the exacerbation of coercive control by the structural inequities associated with gender, class, race and disability. The intersection of the latter manifestations of social entrapment are commonly understood as structural entrapment. Within this context, participants’ experiences of being trapped are acknowledged as manifestations of spiritual entrapment. Much like intimate partner violence, the spiritual abuse described by participants included social isolation, fear and coercion, an indifference of a powerful institution (the faith community), and the compounding of structural inequities experienced by sexual and gender diverse people.

Participants equally stressed that spiritual abuse needs to be appreciated as occurring in environments of harm, reflective of structures that place excessive controls on their members and requiring unwavering devotion to a set of beliefs and inerrancy which were used to other those who fall outside of biblical dictates. Collusion was described as integral to these environments whereby members of the faith community, including family members, collude to change the individual’s sexual orientation, gender identity, and gender expression. Within this vein, environments of harm were commonly referred to as “cults” or “cult-like”, a metaphor that was used across participants regardless of the context in which the conversion practices occurred.

They [fundamentalist faith settings] are cult-like if not actual cults. There are so many barriers to getting out of it; getting into a position where you feel free to leave. (Participant #1)

Complementing the pervasive impact of faith-based environments of harm, participants stressed that it is erroneous to frame conversion practices external to conversion ideology. Effectively, conversion practices exist within environments of harm that negatively frame spiritualised categorisations of those who fall outside of prescribed sexual and gender norms as sexual perversions, inclusive of homosexuality, paedophilia, adultery, and masturbation; all of which the individual can be cured of through the Word of God. Within this context, participants stressed their entry into formal or informal conversion practices had been facilitated by a consistent exposure to deviantised othering.

Conversion practices are pervasive and that is where most damage gets done. I mean, there’s the explicit conversion stuff, but there’s all of what leads you to be vulnerable to that, which is the message that you’re not acceptable the way you are. And that includes the church environment, Christian schools, and the home as well. (Participant #2)

Insidiously, and complementing the metaphor of a cult, participants described that failure to comply with communities of faith directives resulted in their punishment and expulsion. Significantly, narratives positioned the survivor as a contagion, someone to be shunned by members of the faith community, including friends and family or, at the least, having stringent limits placed on interactions. The discourse of contagion is significant as it encapsulates dis-ease and the pervasive, and persistent, impacts.

My parents and brother don’t know where I live. We can’t give them my address because they send hate mail. Well, they send loving messages of how we’re going to go to hell. My partner and I, my son came out as trans five years ago and they cut him off completely. The other thing, because my son came out, I went down a level myself. They could still tolerate me being around their children, my nieces and nephews but once my son came out, I’d become someone who perverted children. And the Bible says that if anyone hurts one of my children, they should have a stone put around their necks and be flung into the sea. As far as they’re concerned, that’s what I am. So now I have zero contact with 12 or 13 of my nieces and nephews. (Participant #3)

The following analysis is structured according to four primary discourses. The first three discourses frame survivor experiences in terms of primary barriers to either identification of experiences as abuse or impediments to the survivor’s healing journey. These include (1) spiritual entrapment, (2) social entrapment, and (3) structural entrapment. A fourth discourse, pipelines to safety and recovery, presents survivor-derived suggestions for survivor-centred intervention and support.

3.2. Spiritual entrapment

Within the cultural dynamics of the faith setting, survivors had been unable to identify conversion practices as abuse; a dynamic that is understandable considering fundamentalist teachings and having been socialised to obey faith leaders’ dictates as emulating “God’s voice on Earth”. Rather than consent, participants stressed they were entrapped in environments that demanded obedience; survivors surrendering choice in lieu of the faith setting’s authority over the individual.

And I think it’s important to say that I did go along with all of this. And I wasn’t forced to take that prescription [chemical castration]. I wasn’t forced to take the drugs. But this was in the context of the church, the leader is God’s voice on Earth. And everything he says is God literally speaking through a man. And he can do no wrong. And so, if you disobeyed the leader, then that was equivalent in many ways to disobeying God. To a young teenager, who’s grown up in this belief system, it was utterly unthinkable that you would disobey what the leader was saying. And if the leader tells you to see a doctor, and then the doctor tells you to take these pills, it’s not even an option to say no because you’d be disobeying God. (Participant #4)

Common to participants’ experiences of spiritual entrapment were examples of psychological abuse where the survivor’s ability to make an informed decision was questioned, either because they were told that they were mentally unwell or they were being influenced by nefarious forces, such as demonic possession. Such manifestations of entrapment were enacted when survivors communicated that they were contemplating either disengaging from formal conversion practices or leaving the faith setting.

When I told the priest that I was leaving the church, they refused to accept it, and they told me that I was mentally unwell. (Participant #5)

Associated with emotional and psychological abuse, participants described examples of punishment, either the possibility or enactment of a threat, which eroded individual agency and reinforced the individual as subservient to those in power. Discursively, these threats commonly reflected a discourse of contagion, whereby the individual had to be removed from the faith community, either physically or symbolically, such as loss of leadership positions, so to contain transmission. Notably, punishment often coincided with the individual’s family being punished; a situation that resulted in considerable guilt for the survivor.

And the crunch point for them [church elders] was when I came out to my siblings, which for them [church elders] was a step too far. After that I was put in the first stage of excommunication, which meant that all members of the church were banned from speaking to me and I was banned from attending church services. That first stage feels like a form of purgatory where you are extremely isolated. (Participant #4)

An especially insidious form of entrapment involved some survivors being removed from their faith communities and sent either overseas or to another location within the country for “intervention” or “treatment”. In all cases, the individual’s placement in unfamiliar settings resulted in heightened levels of isolation and a complete reliance on those with whom they had been “placed” that prevented them from leaving an abusive environment.

Where was I going to go? I never tried to escape, but I didn’t have a phone. I was staying with church people. They were there every waking moment of the day. I didn’t have a credit card and I had no access to communications, no access to the outside world. Assuming that I could have left where was I going to go? (Participant #6)

3.3. Social entrapment

Spiritual entrapment was framed as pervasive, extending beyond the rejection of conversion practices and extrication from abusive faith settings. Formal and informal conversion practice survivors described having lived cocooned existences that had prevented them from engaging in developmental tasks commonly navigated by their secular peers; thereby failing to acquire the life and interpersonal skills needed to function independently as adults, external to the faith environment.

I was six or seven years behind everyone else developmentally. My whole life had been the community. That was all taken away from me—all those people I’d relied on for my guidance, my support. I lost everybody and everything as a 19-year-old. (Participant #7)

Discursively, these experiences reflected variations of social entrapment, denoted by the individual’s extreme isolation and lack of knowledge about how to navigate life external to the abusive faith setting. Commonly cited barriers to engaging in recovery were homelessness, a lack of employable skills, and a lack of financial literacy.

The aftermath of when you are kicked out is horrendous. I didn’t really know what was normal and what wasn’t. There are so many practical things that you have to deal with that you don’t fully have the scope to deal with. I’d never had to cook for myself. I’d never had to do all number of things. And I’d never watched TV. I’d never eaten in a restaurant. I didn’t know how to go to the pub. Suddenly I was in a situation where all of these things that to most people are very mundane, everyday occurrences were brand new to me and they took a huge amount of psychological labour and the labour of learning those new processes was so overwhelming. (Participant #8)

Significantly, participants’ social entrapment was aggravated by heightened levels of vulnerability, anxiety, suicidality, self-loathing, and identity confusion that accompanied their exit from faith communities: the internalisation of cis-heteronormative messaging acting to prevent either entry to, or authentic integration within, “queer” networks.

I had months of feeling like an absolute failure because I hadn’t been able to change. I was now going to live this life that wasn’t fully satisfying, a life of misery or whatnot. I just thought, well, that’s better than what I was experiencing before. (Participant #9)

Finally, some participants shared having been financially entrapped, having acquired student loans to pay for their Bible college studies and being required to pay for these following their expulsion. These instances of financial entrapment were especially difficult for the survivors as the loans had implicitly funded their formal conversion practices and the required repayments had a detrimental impact on their ability to live independently.

3.4. Structural entrapment

Various manifestations of structural entrapment, reinforced by institutional inaction and non-inclusion through legislation or the lack of provision for intervening and supporting spiritual abuse survivors, were identified as creating significant barriers to the individual leaving abusive religious settings or the individual’s healing, post-conversion practices.

3.5. Lack of systemic intervention and support

A lack of systemic support was voiced as contributing to the individual’s entrapment within abusive religious structures and placing the individual at increased levels of vulnerability; this was especially noted in reference to faith-run schools and those who are homeschooled, whereby students are shielded from exposure to alternative discourses that legitimise otherness. Moreover, in the absence of interventions that can support an individual to leave an abusive environment, and reinforced by legislation that places the individual under the protection of the family, many victims are forced to remain in environments of harm.

There are always going to be lonely kids lost in churches who have no way out. Their only option is to wait until they are old enough to leave. If you are 12 and being told that you are evil, that means you have six years ahead of you until you are old enough to leave to go to university. It’s either wait and live in hell or live on the streets. That’s a terrible place to put a young person in. When I was that age, I thought suicide was my only option. (Participant #11)

3.6.Pipeline to safety and recovery

Spiritual abuse was analogously aligned to family and sexual violence, and participants variously enlisted the metaphor of a pipeline to describe a multidimensional set of interventions required to ensure those entrapped within spiritual abuse have a “pipeline to safety”. Significantly, the pipeline needs to provide support to survivors while they are entrenched within abusive religious settings, immediately after they have left abusive environments, and throughout their healing journeys.

We need to be able to get victims out of families and environments that are abusive. They need to know that they can leave, and they need to know how to leave. I am thinking something like a Women’s Refuge model. (Participant #3)