Geographic distribution of conversion therapy prevalence in Canada. Findings from a national cross-sectional survey, 2020

Amrit Tiwana; Travis Salway; Julia Schillaci-Ventura; Sarah Watt

doi:10.12688/f1000research.134292.2

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Research Article

Revised

Geographic distribution of conversion therapy prevalence in Canada. Findings from a national cross-sectional survey, 2020

[version 2; peer review: 2 approved, 1 approved with reservations]

Amrit Tiwana¹, Travis Salway¹, Julia Schillaci-Ventura², Sarah Watt¹

PUBLISHED 15 Aug 2024

Author details Author details

¹ Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
² Department of Psychology, Simon Fraser University, Burnaby, British Columbia, Canada

Amrit Tiwana
Roles: Conceptualization, Data Curation, Formal Analysis, Methodology, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Travis Salway
Roles: Conceptualization, Formal Analysis, Funding Acquisition, Investigation, Methodology, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing

Julia Schillaci-Ventura
Roles: Data Curation, Methodology, Writing – Review & Editing

Sarah Watt
Roles: Conceptualization, Methodology, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS

Abstract

Background: Conversion therapy practices (CTPs) are discredited efforts that target lesbian, gay, bisexual, trans, queer, Two-Spirit, or other (LGBTQ2S+) people and seek to change, deny, or discourage their sexual orientation, gender identity, and/or gender expression. This study aims to investigate the prevalence of CTPs across Canadian provinces and territories and identify whether CTP bans reduce the prevalence of CTPs. Methods: We collected 119 CTPs from 31 adults (18+) in Canada who have direct experience with CTPs, know people who have gone to CTPs, or know of conversion therapy practitioners using a 2020 anonymous online survey. Mapping analysis was conducted using ArcGIS Online. CTP prevalence was compared between provinces/territories with and without bans using chi-square tests. Results: Three provinces and eleven municipalities had CTP bans. The prevalence of CTPs in provinces/territories with bans was 2.34 per 1,000,000 population (95% CI 1.65, 3.31). The prevalence of CTPs in provinces/territories without bans was 4.13 per 1,000,000 population (95% CI 3.32, 5.14). Accounting for the underlying population, provinces/territories with the highest prevalence of CTPs per 1,000,000 population were New Brunswick (6.69), Nova Scotia (6.50), and Saskatchewan (6.37). Conclusions: Findings suggest only 55% of Canadians were protected under CTP bans. The prevalence of CTPs in provinces/territories without bans was 1.76 times greater than provinces/territories with bans. CTPs are occurring in most provinces/territories, with higher prevalence in the west and the Atlantic. These findings and continued efforts to monitor CTP prevalence can help inform policymakers and legislators as society is increasingly acknowledging CTPs as a threat to the health and well-being of LGBTQ2S+ people.

Keywords

Canada, conversion therapy, LGBTQ2S+ health, health policy, public health, sexual and gender minorities, social epidemiology, spatial analysis

Corresponding author: Amrit Tiwana

Competing interests: No competing interests were disclosed.

Grant information: This study was supported by the Canadian Institutes of Health Research (FRN: PCS - 168193), Andrew Beckerman, and the Victoria Foundation. The funding sources did not play a role in the study design, the collection and analysis of data, the decision to publish or the preparation of the manuscript.
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Copyright: © 2024 Tiwana A et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Tiwana A, Salway T, Schillaci-Ventura J and Watt S. Geographic distribution of conversion therapy prevalence in Canada. Findings from a national cross-sectional survey, 2020 [version 2; peer review: 2 approved, 1 approved with reservations]. F1000Research 2024, 12:844 (https://doi.org/10.12688/f1000research.134292.2) First published: 18 Jul 2023, 12:844 (https://doi.org/10.12688/f1000research.134292.1) Latest published: 15 Aug 2024, 12:844 (https://doi.org/10.12688/f1000research.134292.2)

Revised Amendments from Version 1

In this revised version of our article, we have made several key updates and improvements. First, we clarified the language and structure of the Introduction and Discussion sections to enhance readability and precision. Specifically, we rephrased sentences that were previously cumbersome or confusing, such as the timeline references and the identification of study findings. We also addressed inconsistencies in verb tense throughout the manuscript, ensuring uniformity in how we refer to Conversion Therapy Practices (CTPs) and Sexual Orientation and Gender Identity Change Efforts (SOGIECE).

Additionally, we updated our references to reflect the most current data, correcting inaccuracies and ensuring that each source aligns appropriately with the content discussed. Finally, we refined our discussion of the differences in findings between our study and previous research, providing a clearer explanation of potential reasons for these discrepancies, such as variations in survey methodologies and sample sizes. These revisions collectively improve the clarity, accuracy, and relevance of our article, ensuring it better serves the needs of our readers and the academic community.

See the authors' detailed response to the review by Travis Scheadler
See the authors' detailed response to the review by Sean Mulcahy

Introduction

“Conversion therapy” practices (CTPs) are widely discredited, yet they continue to occur across the globe, including Canada.¹ CTPs refer to any practice designed to change, deny, or discourage: one’s feelings of sexual attraction to members of the same gender; lesbian, gay, bisexual, trans, queer, Two-Spirit, or other (LGBTQ2S+) identity; non-conforming gender expression; or gender identity that differs from sex at birth.²^,³ These practices come in many forms and are also sometimes referred to by other names including sexual orientation and gender identity and expression change efforts (SOGIECE), aversion therapy, reparative therapy, and ex-gay ministries.⁴

SOGIECE are not monolithic or clearly delineated practices, given that they can happen in many forms. In some contexts, a distinction between CTPs and SOGIECE is useful. CTPs are typically organized (i.e., structured activities) and circumscribed (e.g., a certain number of sessions with a practitioner); these practices are, metaphorically, only the “tip of the iceberg”, representing visible and formally recognized forms of efforts to change LGBTQ2S+ identities.⁵ CTPs are underpinned by more prevalent practices including other forms of SOGIECE and cissexist and heterosexist attitudes. SOGIECE have a similar aim as CTPs, but also include practices that are less well defined and advertised. For example, a conversation between a parent and a child in which the child is dissuaded from living with or adopting a LGBTQ2S+ identity constitutes as SOGIECE. Overall, both CTPs and SOGIECE are enabled and condoned by widespread heterosexism and cissexism in societies.³

CTPs are performed by licensed health care providers (e.g., psychologists, psychiatrists, and psychotherapists) and unlicensed practitioners.⁶ They have also been performed by ex-gay ministries (e.g., EXODUS) and religious leaders (e.g., pastoral counsellors).⁷ CTP attempts may also involve parents, government agencies, and school personnel.⁶ They may be performed one-on-one in an office or in groups at retreats or conferences.⁴ Providers may perform CTPs for money or for free.⁴ CTPs can include the use of aversive stimuli, individual talk therapy, participation in activities that are typically gendered by social norms and processes (e.g., sports, hunting, fishing, cooking, playing with dolls, etc.), forced sex, and praying and bible study.⁶

The harms of conversion therapy

There is no credible scientific research that proves CTPs are psychologically safe or effective.⁸ Many medical and human rights associations (e.g., World Health Organization, Canadian Psychological Association, Canadian Psychiatric Association, American Medical Association, American Psychological Association, American Academy of Pediatrics, and Amnesty International) have denounced and discredited the effectiveness of CTPs.³^,⁴^,⁸^,⁹ However, due to continuing discrimination and societal bias against LGBTQ2S+ people and others with non-heterosexual identities/attractions and non-cisgender identities/expressions, some practitioners continue to provide CTPs, particularly to minors, making them vulnerable to harms associated with these practices.⁹

Previous research suggests that CTPs negatively impact and stigmatize LGBTQ2S+ people, and can lead to increased anxiety, depression, self-hatred, post-traumatic stress disorder (PTSD), and many lifelong psychological and social issues.⁴^,⁸^–¹⁰ According to the Sex Now 2011/12 survey, exposure to SOGIECE among Canadian gay, bisexual, and other sexual minority men were positively associated with loneliness, regular illicit drug use, suicidal ideation, and suicide attempt.¹⁰

LGBTQ2S+ health disparities are often conceptualized through the minority stress framework, in which mental health problems found among LGBTQ2S+ people are the result of chronic stressors stemming from the marginalized social status of these individuals, rather than a function of their identity itself.¹¹^–¹³ This framework offers some insight into the mechanisms through which CTPs may exact harm upon people who experience them.¹⁴ Minority stressors include prejudicial events and conditions that are expressed both interpersonally (e.g., violent attacks and discrimination) and structurally (e.g., laws allowing the rejection of LGBTQ2S+ people in employment).¹⁵ SOGIECE can also be conceptualized as a minority stressor because it promotes cisheteronormativity as the only acceptable way of life and reinforces the rejection of LGBTQ2S+ identities.¹⁵ Cisheteronormativity refers to “cissexism and heterosexism which assume cisgender gender identities and heterosexual orientation are more natural and legitimate than those of LGBTQ2S+ people”.⁵ As these stressors (including SOGIECE) accumulate, they create emotional (e.g., ruminating on negative messages), cognitive (e.g., feeling negatively about oneself and/or hopeless about one’s future), and social (e.g., social anxiety/avoidance) maladaptive responses, eventually leading to diagnosable conditions like anxiety or depression.¹⁴

Prevalence of conversion therapy

According to the survey results from Sex Now 2019 (SN2019), an estimated 50,000 Canadian gay, bisexual, and other sexual minority men have attended CTPs at some point in their lives.¹⁰ This corresponds to 1 in 10 gay, bisexual, and other sexual minority men (10%) having reported experiencing CTPs. In addition, the previous Trans PULSE Canada community-based survey found that 11% of transgender and non-binary people had undergone SOGIECE.¹⁶ Additionally, results from SN2019 suggest that transgender and non-binary people experience a higher burden of exposure to CTPs than cisgender people.¹⁷

Results from SN2019 did not find a difference in the prevalence of CTPs across provinces and territories in Canada.¹⁰ However, it did find uneven exposure of CTPs across groups defined by age, gender identity, immigration, and ethnicity.¹⁰ CTPs were even more common (i.e., more than 10%) among subgroups including youth 15-19 years of age (13%), immigrants (15%), and racial/ethnic minorities (11-22%).¹⁷ Besides the annual Sex Now Surveys and Trans PULSE Canada Survey, no data are available regarding the distribution of CTPs in Canada. Further, no data are available examining the geospatial patterning of CTPs across and within different geographic regions of Canada, highlighting the importance of the current study.

Attempts to ban conversion therapy

As of November 11, 2021, five Canadian provinces and territories (Ontario, Nova Scotia, Prince Edward Island (PEI), Quebec, and Yukon) and dozens of Canadian municipalities (including Calgary, Edmonton, and Vancouver) had enacted legislative bans on CTPs.¹⁸ On December 4, 2021, the Canada House of Commons voted unanimously to pass Bill C-4, an Act to Amend the Criminal Code (conversion therapy). Bill C-4 subsequently was passed by the Senate and received Royal Assent on December 8, 2021. Bill C-4 included provisions to prohibit causing a person to undergo CTP for, removing a child from Canada to undergo CTP outside Canada, and advertising or financially benefiting from CTP. This federal law defined CTP in relation to both sexual orientation and gender identity. While provincial/territorial bans have predominantly focused on clinical settings, the federal law applies to all settings, including those outside licensed healthcare. Municipal bans typically operate through prohibition of CTP under bylaws governing the provision of business licences.¹⁹ However, informal practices like parent-child conversations are typically not covered by these bans. Nonetheless, legislation represents an important milestone in the government’s commitment to protecting LGBTQ2S+ people. As policymakers and legislators are increasingly acknowledging CTPs as a threat to the health and well-being of LGBTQ2S+ people, up-to-date data on the geospatial patterns of CTP prevalence are urgently needed.

Given that CTPs have been banned in many parts of Canada, many conversion therapy providers do not advertise themselves as “conversion therapists”.²⁰ Wide denunciation and steps towards criminalization may have led conversion therapy providers to operate ‘underground’ and advertise their services in covert ways.²¹ These providers may not refer to their services as “conversion therapy” and may instead use vague terms to allude to their approach to diverse sexual orientations or gender identities (e.g., healing “sexual brokenness”).²¹ Moreover, official data on enforcement of bans are absent, and many who experience CTP may choose not to disclose their experiences owing to feelings of shame.²² For these reasons, it is challenging to track down the locations of where CTPs continue to operate. Establishing methods and data sources that enable ongoing monitoring of CTPs is critical in this context.

The purpose of this research

For this study, data were collected from a small national sample of Canadians who have direct experience with CTPs, know people who have gone to CTPs, or know of conversion therapy practitioners in 2020. The goal of the survey was to better understand the nature and scope of SOGIECE, or CTPs in Canada. The primary objective of this thesis was to estimate the spatial patterning of prevalent CTPs in Canada.

Methods

Study design

This research uses a cross-sectional study design to examine the spatial prevalence of conversion therapy across Canadian provinces and territories. We asked Canadians who have direct experience with CTPs, know people who have gone to CTPs, or know of conversion therapy practitioners using an online survey. Participants were also asked to provide socio-demographic information such as age, sexual orientation, gender identity, race/ethnicity, and place of residence. This article was previously published as a preprint on medRxiv, a preprint server for health sciences.²² A novel questionnaire was developed with input from people who have directly experienced CTPs and from LGBTQ2S+ community partners. Wording of items was adjusted based on face validity considerations from these stakeholders. A copy of the questionnaire can be found under Extended data.³⁰

Participants

An anonymous online survey using SurveyMonkey was conducted between August 18 and December 2, 2020. The survey was conducted in French and English. To be eligible for the survey, participants must have: experienced CTPs, nearly experienced CTPs or know someone who has experienced CTPs; been 19 years of age or older; and resided in Canada. The protocol for this study was approved by the Simon Fraser University Research Ethics Board (study 2019s0394).

Participants were recruited using various strategies including word-of-mouth (37% of respondents reported hearing about the survey by this manner), Twitter or Facebook (35%), LGBTQ2S+ community organizations (15%), and participation in an in-depth interview with the research team²³ during January-July 2020 (13%). A total of N = 108 individuals entered the study, of which 19 did not consent to participate and/or were ineligible to participate. In total, N = 89 completed the entire survey (i.e., provided a response to the last question). For the present study, a subset of N = 31 (29%) of those who answered the questions regarding known conversion therapy providers in Canada were used in the analysis.

Measures

Participants were directed to a SurveyMonkey link where they were presented with an informed consent page regarding the study. Specifically, participants were informed about the project, who were conducting and funding the survey, the risks and benefits of the survey, as well as the eligibility criteria and consent to participate. All participants who completed the survey (N = 89) provided informed consent prior to completing the questionnaire. Participants were informed they could skip any of the questions they did not wish to answer.

The survey consisted of six parts: (1) recruitment and category of experience with conversion therapy; (2a) details about direct SOGIECE experience; (2b) details about knowledge of SOGIECE; (3) knowledge of conversion therapy practitioners; (4) legislative action against conversion therapy; and (5) social-demographic characteristics. To determine eligibility, participants were asked: “How would you describe your experience with conversion therapy (i.e., structured activity to deny or suppress your LGBTQ2 identity)? Please check all that apply.” Respondents were directed to part (3) of the survey, ‘knowledge of conversion therapy practitioners’, if they selected “I know of conversion therapy practitioners in Canada” or “I know that conversion therapy is happening in Canada”. They were then asked to list municipalities, provinces, and territories where these CTPs had taken place, and identify whether the practice was ongoing or historical (i.e., happened in the past).

At the end of the study, all participants were asked to provide social demographic information including their age, place of residence, and racial/ethnic group. Finally, participants were presented with a debriefing letter which included an option to input their email address to learn more about SOGIECE and CTPs, and a list of LBTQ2S+-affirming mental health supports for any participants who may have experienced distress because of the recalling of traumatic experience(s).

Analyses

To analyze the spatial patterning, maps were created using ArcGIS Online. Participants who answered part (3) of the survey, ‘knowledge of conversion therapy practitioners’ (N = 31) were used in the mapping analysis. The dataset contained a total of 127 reports of 119 ongoing and 8 historical CTPs. Because names/addresses of CTPs were not collected, it was not possible to determine whether the 127 reports are mutually exclusive. Municipal and provincial/territorial spatial units were used in the analysis. Primary analysis focused only on ongoing reports, however additional maps were created combining ongoing and historical reports (see Extended Data).³¹ Thus, the primary analysis dataset consisted of 119 rows (i.e., observations) and 2 columns (reported municipalities and provinces/territories). These 119 CTPs were identified in 53 different municipalities (with 1-7 CTPs per municipality) and 8 different provinces/territories (with 1-28 CTPs per province/territory). 20 out of the 119 reports identified CTPs in provinces/territories but did not specify a municipality.

Three maps were created: (1) municipal, provincial and territorial CTP bans in Canada, (2) a heat map of ongoing CTPs (using municipal spatial unit), and (3) a choropleth map of CTP prevalence by province/territory (calculated as reports of ongoing CTPs divided by 1,000,000 population per province/territory). Provinces/territories with numerators less than 5 were not interpreted due to statistical instability. As of November 2021, data on current legislative bans were obtained from the Legislation Map on the No Conversion Canada website (Wells, n.d.). The “heat map” function in ArcGIS Online was applied to identify hot spots of CTPs across the nation. The map of the bans and the heat map were compared to assess the association between ongoing CTPs and existing bans. We also calculated the prevalence of CTPs in provinces/territories with bans and the prevalence of CTPs in provinces/territories without bans (as of the time of survey, August 2020) using chi-square tests, to assess differences in prevalence between these two sets of jurisdictions. 95% confidence intervals were added to these measures. The 2016 Census cartographic boundary file by Statistics Canada was used to estimate the population per municipality, province, and territory for the choropleth map.²⁴

Results

The age of respondents ranged from 18 to 65+ with 70% of participants under age 45. The majority of the respondents resided in the most populous Canadian provinces, i.e., British Columbia, Ontario, and Alberta. The majority of the sample identified with a white ethnic/racial group (93.33%), followed by East Asian, Black, and mixed ethnic/racial groups. A plurality of respondents identified as cis men (38.7%) and gay (41.9%). However, reported gender identity and sexual orientation were diverse, as shown in Table 1.

Table 1. Demographic characteristics of participants who report knowing ongoing or historical conversion therapy practices in Canada, (N = 31).

Demographic characteristics		Total n (%)
Age (years)	18-24	6 (20)
	25-34	9 (30)
	35-44	7 (22.6)
	45-54	3 (10)
	55-64	2 (6.7)
	65+	1 (3.3)
	N/A	3 (10)
Area of Residence (Province/Territory)	British Columbia	8 (26.7)
	Alberta	4 (13.3)
	Saskatchewan	0
	Manitoba	0
	Ontario	9 (30)
	Quebec	3 (10)
	Atlantic	3 (10)
	Territories	0
	N/A	3 (10)
Race/Ethnicity	White	19 (63.3)
	Black	2 (6.7)
	East Asian	3 (10)
	Indigenous	1 (3.3)
	Mixed	2 (6.7)
	N/A	3 (10)
Gender identity*	Cis Men	12 (38.7)
	Cis Women	5 (16.1)
	Trans Men	5 (16.1)
	Trans Women	2 (6.5)
	Non-Binary	5 (16.1)
	Genderqueer	3 (9.7)
	Genderfluid	2 (6.5)
Sexual orientation*	Gay	13 (41.9)
	Queer	12 (38.7)
	Lesbian	6 (19.4)
	Bisexual	4 (12.9)
	Pansexual	4 (12.9)
	Asexual	2 (6.5)
	Heterosexual/straight	4 (12.9)
	Queer Stone Butch	1 (3.2)

* Participants permitted to select more than one option.

Data collection took place between August and December 2020, therefore legislative bans passed on CTPs after August 2020 are not considered in the results. At that point in time, only three provinces (Ontario, PEI, and Nova Scotia) and eleven municipalities had legislative bans in place. As shown in Table 2, 19,459,172 out of 35,151,728 Canadians were protected under legislative bans as of August 2020, which corresponds to 55.1% of the total Canadian population. Figure 1 is a map visualizing the bans passed as of August 2020.

Table 2. List of the dates of legislative bans passed on conversion therapy practices (CTPs) in Canadian municipalities, provinces, and territories.

Municipality	Province/Territory	Date of legislative bans on CTPs	Canadian population, 2016	Cumulative percentage of Canadian population protected under legislative ban
	Ontario	2015	13,448,494	38.3%
Vancouver	British Columbia	June 2018	631,486	40.1%
	Nova Scotia	2018	923,598	42.7%
Montreal	Quebec	August 2019	1,704,694	47.5%
Strathcona County	Alberta	September 2019	98,044	47.8%
Edmonton	Alberta	December 2019	932,546	50.5%
St. Albert	Alberta	December 2019	65,589	50.7%
	Prince Edward Island	2019	142,907	51.1%
Wood Buffalo (Fort McMurray)	Alberta	January 2020	71,589	51.3%
Saint John	New Brunswick	January 2020	67,575	51.5%
Rocky Mountain House	Alberta	February 2020	6,635	51.5%
Calgary	Alberta	March 2020	1,239,220	51.5%
Spruce Grove	Alberta	April 2020	34,066	55.0%
Lethbridge	Alberta	July 2020	92,729	55.1%
Data collection occurred August-December 2020. Therefore, the following legislative bans are not accounted for in the analysis.
Beaumont	Alberta	November 2020	17,396	55.4%
	Yukon	November 2020	35,874	55.4%
	Quebec	December 2020	8,164,361	78.1%
Kingston	Ontario	January 2021	123,798	79.1%
Saskatoon	Saskatchewan	February 2021	246,376	79.8%
Nanaimo	British Columbia	March 2021	90,504	80.0%
Fort Saskatchewan	Alberta	July 2021	24,149	80.1%
Strathmore	Alberta	July 2021	13,756	80.2%
Thunder Bay	Ontario	July 2021	107,909	80.5%
Regina	Saskatchewan	August 2021	215,106	81.1%

Figure 1. Municipal, provincial, and territorial legislative bans on conversion therapy practices (CTPs) in Canada as of August 2020.

31 out of the 89 participants who answered part (3) of the survey, ‘knowledge of conversion therapy practitioners’ reported 119 CTPs (reports per participant ranged from 1-31, mean of 4). 20 (16.8%) locations were reported at the provincial/territorial level and 99 (83.2%) locations were reported at the municipal level. As shown in Table 3, the prevalence of ongoing CTPs in provinces and territories with bans as of August 2020 is 2.34 per 1,000,000 population (95% CI 1.65, 3.31). The prevalence of ongoing CTPs in provinces and territories without bans as of August 2020 is 4.13 per 1,000,000 population (95% CI 3.32, 5.14). No data were reported regarding CTPs in the Northwest Territories and Nunavut and therefore are not included in the calculations.

Table 3. Prevalence of ongoing conversion therapy practices (CTPs) in Canadian provinces and territories with bans versus without bans at the provincial level.

	Number of practices identified (numerator)	Prevalence (CTPs per 1,000,000) (95% confidence interval)
Ongoing CTPs per 1,000,000 population in provinces/territories WITH bans (as of August 2020):	34	2.34 (1.65, 3.31)
Ongoing CTPs per 1,000,000 population in provinces/territories WITHOUT bans (as of August 2020):	85	4.13 (3.32, 5.14)

A heat map was created to examine a more granular prevalence of reported ongoing CTPs in Canada using count data without adjustment of the underlying population. We used the municipal spatial unit for the heat map because data containing just the reported province/territory were misleading. As shown in Figure 2, ongoing CTPs were identified across the nation. Many of the cases and hotspots are clustered around the South of Canada. This is no surprise given that two-thirds (66%) of the Canadian population lives within 100 kilometres of the southern Canada-United States (US) border, an area that represents approximately 4% of Canadian land.²⁵

Figure 2. A heat map of the prevalence of reported ongoing conversion therapy practices (CTPs) in Canada using count data (N = 99).

Note. No data were reported regarding the prevalence of CTPs in the Northwest Territories and Nunavut.

Figure 3 displays the prevalence of CTPs divided by 1,000,000 population per province/territory. When accounting for the underlying population, the provinces and territories with the highest prevalence of reported ongoing CTPs are New Brunswick (6.69), Nova Scotia (6.50), and Saskatchewan (6.37). Provinces and territories with moderate prevalence include British Columbia (6.08), Alberta (5.90), and Manitoba (3.91), Provinces with lower prevalence include Ontario (2.01), and Quebec (1.59). The following provinces/territories had <5 reports of CTPs and therefore are not further interpreted: Yukon (55.75), PEI (7.00), and Newfoundland and Labrador (1.92). No data were reported regarding the prevalence of ongoing CTPs in the Northwest Territories and Nunavut.

Figure 3. Prevalence of ongoing reported conversion therapy practices (CTPs) divided by 1,000,000 population per province/territory (N = 119).

Note. *Province/territory has implemented a ban as of August 2020. Please exercise caution in interpreting estimates from the following provinces/territories with numerators <5: Yukon (YT) (55.75), Prince Edward Island (PEI) (7.00), Newfoundland and Labrador (NL) (1.92). No data were reported regarding the prevalence of CTPs in the Northwest Territories and Nunavut.

Discussion

This non-probabilistic survey of adults in Canada with direct or indirect experiences of CTPs provides early insights on the spatial patterning of the prevalence of CTPs in Canada. Findings suggest only 19,459,172 out of 35,151,728 Canadians were protected under legislation on CTPs at the time of the study. This number corresponds to 55.1% of the total Canadian population protected. Further, CTPs are occurring in majority of Canadian provinces and territories, with higher prevalence in the west and the Atlantic.

These findings are similar to the results of a study which examined exposure to psychological attempts to change a person’s gender identity from transgender to cisgender (PACGI) among transgender people in the US.²⁵ The authors explored this issue between 2010 and 2015 across US states, finding that PACGI continued to occur in every state despite major US medical organizations identifying PACGI as ineffective, and legislative bans being implemented in 20 states and over 100 municipalities throughout the US.²⁶ As with the Canadian map (see Extended Data),³¹ the US PACGI study found elevated prevalence of PACGI in western jurisdictions of the US. On the other hand, the SN2019 study did not find a difference in the prevalence of CTPs across provinces and territories in Canada. The difference in findings between SN2019 and our study may be due to differences in survey methodologies or sample sizes, as our study used a more targeted approach to recruit participants with direct or indirect experiences of CTPs.

The prevalence of CTP in provinces/territories without legislative bans as of August 2020 was approximately 1.76 times greater than the prevalence in provinces/territories with bans (Ontario, PEI, Nova Scotia). While this is encouraging, there are several reasons to be cautious in interpreting this finding. The data used in this analysis does not allow us to control for other factors happening within the provinces/territories with bans that have deterred CTPs (i.e., confounding). For example, we did not account for whether there might have been an effect of municipal bans. Additionally, we cannot know from these data whether bans are enforced. We cannot say whether legislative bans caused CTPs to shut down because we do not know whether these services started or stopped practicing before or after the bans. In other words, we cannot assess the temporal relationship between time and practices taking place. For these reasons, the association between the lower prevalence found in provinces/territories with bans and higher prevalence found in provinces/territories without bans may not be real. Despite this, our study emphasizes the urgent need for nationwide legislative bans against CTPs in Canada. Areas without bans continue to experience significantly higher prevalence rates, highlighting the ongoing harm inflicted on LGBTQ2S+ individuals. Comprehensive bans, along with rigorous enforcement and support for affected communities, are essential steps toward mitigating these harmful practices and promoting inclusive and affirming environments nationwide.

Limitations

The present study is not without limitations. First, the sample size was small. The prevalence calculated may be unstable because it is based upon only a small number of reported CTPs extrapolated over a large population.²⁸ The study included only 31 participants, which limits our ability to make broad generalizations. Second, the sample largely came from LGBTQ2S+ community organizations or conversion therapy survivors and thus constitutes a non-probabilistic subset of the total target population (e.g., all people in Canada). Evidence shows non-probability surveys tend to overrepresent employed, high-income-earning, and gay-identified sexual minorities.²⁹ Third, since the survey was developed in Vancouver, British Columbia, it is likely more CTPs were reported in this region compared to other parts of Canada, which is reflected in the geographic patterning of the data. Fourth, the language of the item used to measure conversion therapy may not encompass people’s experiences. For example, people may interpret their experience as more of a form of SOGIECE rather than conversion therapy and thus may choose to not report the practice. Fifth, it was not possible to determine whether the reports were mutually exclusive. This means that the same practice could have been reported multiple times, potentially overemphasizing the prevalence of CTPs in a particular province or territory. Sixth, conclusions about certain regions, such as Prince Edward Island, cannot be reached because they were excluded from the analysis due to having fewer than five reports of CTPs. This exclusion could lead to an incomplete estimation of the prevalence and distribution of CTPs across Canada. Lastly, we cannot assess the temporal relationship between legislation and CTPs from these data. We do not know if the identified practices occurred before or after legislative bans were enacted, which limits our ability to evaluate the effectiveness of these bans.

Future research

Given that CTPs persist across Canada, we recommend that the following actions be taken in collaboration with conversion therapy survivors, community organizations and multiple levels of government. The results of this study should be confirmed and repeated with a larger sample size to ensure representativeness. One idea to deal with the small sample size problem is to bring additional years of data into the analysis to increase the size of the numerator.²⁸ In addition to this, recruitment methods should be expanded to make interpretations more generalizable to the Canadian population. There must be continued efforts to monitor how conversion therapy practitioners continue to operate, even in places where bans have been implemented. Monitoring where CTPs continue to occur will help keep legislators accountable and identify where supportive LGBTQ2S+-affirming environments are most needed.

Conclusion

The ongoing occurrence of CTPs is a serious public health issue impacting the health and well-being of thousands of LGBTQ2S+ Canadians. Findings from this study should be taken into consideration as Bill C-4 is implemented and enforced in Canada. Combined with legislative ban efforts, the Canadian government should work to deter SOGIECE and CTPs, while encouraging LGBTQ2S+-affirming environments by supporting gay straight alliances, pride flags and other interventions that remind LGBTQS2+ people that their identities are valid.³ Finally, education is required to reduce the prejudice of LGBTQ2S+ people to ultimately put an end to CTPs.

Ethical considerations

The protocol for this study was approved by the Simon Fraser University Research Ethics Board (study 2019s0394).

Data availability

Underlying data

Due to the sensitive nature of this research, participants in this study did not agree for their data to be shared publicly. Aggregated data that support the findings of this study are available from the principal investigator (TS) upon reasonable request. Additional requests for data must be directed to the SFU Research Ethics Board, dore@sfu.ca.

Extended data

Tiwana A, Salway T, Schillaci-Ventura J, & Watt S. (2023). Survey About “Conversion Therapy” in Canada. Zenodo. https://doi.org/10.5281/zenodo.7981897.³⁰

Tiwana A, Salway T, Schillaci-Ventura J, & Watt S. (2023). Sensitivity analysis: ongoing and historical conversion therapy practices (CTPs) in Canada. Zenodo. https://doi.org/10.5281/zenodo.8136543.³¹

This project contains the following extended data:

• Questionnaire.pdf
• Sensitivity analysis figures

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

Reporting guidelines

See STROBE guideline attached separately. Repository name: STROBE checklist and flowchart for geographic distribution of conversion therapy prevalence in Canada.

Acknowledgements

Our research team is grateful to the following individuals who provided insight and feedback on the questionnaire drafts, and/or who helped to promote the survey and have given permission to be named in this article: A.J. Lowik, Beth Carlson-Malena, David Kinitz, Elisabeth Dromer, Geron Malbas, Keith Murray, Kiffer Card, Michael Kwag, Nicholas Schiavo, and Trevor Goodyear.

References

1. Bishop A: The Global Reach of So-Called Conversion Therapy. OutRight Action International; 2019. Reference Source
2. Ashley F: Model law – prohibiting reparative practices. SSRN Electron. J. 2019. Publisher Full Text
3. Centre for Gender and Sexual Health Equity: Ending conversion therapy in Canada: Survivors, community leaders, researchers, and allies address the current and future states of sexual orientation and gender identity and expression change efforts.2020 Feb 18. Reference Source
4. The Trevor Project: About Conversion Therapy.2020 Dec 20. Reference Source
5. Kinitz DJ, Goodyear T, Dromer E, et al.: “Conversion therapy” experiences in their social contexts: A qualitative study of sexual orientation and gender identity and expression change efforts in Canada: Les Expériences de “thérapie de conversion” dans leur contexte social: Une étude qualitative des efforts de changement de l’orientation sexuelle, de l’identité de genre et de l’expression de genre au Canada. Can. J. Psychiatr. 2021; 67: 441–451. Publisher Full Text
6. Adamson TM, Wallach S, Garner A, et al.: The global state of conversion therapy - a preliminary report and current Evidence Brief.2020. Publisher Full Text
7. Karten EY, Wade JC: Sexual orientation change efforts in men: A client perspective. J. Mens Stud. 2010; 18(1): 84–102. Publisher Full Text
8. Wells K: Conversion therapy in Canada: A guide for legislative action. Revised Edition.MacEwan University; 2020. Reference Source
9. The Human Rights Campaign: The lies and dangers of “conversion therapy”.Reference Source
10. Salway T, Ferlatte O, Gesink D, et al.: Prevalence of exposure to sexual orientation change efforts and associated sociodemographic characteristics and psychosocial health outcomes among Canadian Sexual Minority men. Can. J. Psychiatr. 2020; 65(7): 502–509. PubMed Abstract | Publisher Full Text | Free Full Text
11. Green AE, Price-Feeney M, Dorison SH, et al.: Self-reported conversion efforts and suicidality among US LGBTQ youths and young adults, 2018. Am. J. Public Health. 2020; 110(8): 1221–1227. PubMed Abstract | Publisher Full Text | Free Full Text
12. Meyer IH: Prejudice, social stress, and Mental Health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychol. Bull. 2003; 129(5): 674–697. PubMed Abstract | Publisher Full Text | Free Full Text
13. Rich AJ, Salway T, Scheim A, et al.: Sexual minority stress theory: Remembering and honoring the work of Virginia brooks. LGBT Health. 2020; 7(3): 124–127. PubMed Abstract | Publisher Full Text
14. Hatzenbuehler ML: How does sexual minority stigma “get under the skin”? A psychological mediation framework. Psychol. Bull. 2009; 135(5): 707–730. PubMed Abstract | Publisher Full Text | Free Full Text
15. Blosnich JR, Henderson ER, Coulter RW, et al.: Sexual orientation change efforts, adverse childhood experiences, and suicide ideation and attempt among sexual minority adults, United States, 2016–2018. Am. J. Public Health. 2020; 110(7): 1024–1030. Publisher Full Text
16. The Trans PULSE Canada Team: QuickStat #1 - Conversion Therapy.2019 Dec 12. Reference Source
17. Salway T, Juwono S, Klassen B, et al.: Experiences with sexual orientation and gender identity conversion therapy practices among sexual minority men in Canada, 2019–2020. PLoS One. 2021; 16(6): e0252539. PubMed Abstract | Publisher Full Text | Free Full Text
18. Wells K: Legislation Map. No Conversion Canada.Reference Source
19. Wells K: Conversion therapy in Canada: The roles and responsibilities of municipalities. Edmonton, AB: MacEwan University; 2019.
20. Brush J: Conversion Ministries and Ex-Gay Ministries. Ohio Psychological Association; 2021 Jan 29. Reference Source
21. Tiwana A: Identifying harmful “conversion therapy” practices in all its forms. MindMapBC; 2021 Oct 2. Reference Source
22. Goodyear T, Kinitz DJ, Dromer E, et al.: “They want you to kill your inner queer but somehow leave the human alive”: Delineating the impacts of sexual orientation and gender identity and expression change efforts. J. Sex Res. 2021; 59: 599–609. Publisher Full Text
23. Tiwana A, Salway T, Schillaci-Ventura J, et al.: Geographic distribution of conversion therapy prevalence in Canada. MedRxiv. 2022. Publisher Full Text
24. Statistics Canada: 2016 Census Boundary Files.2019 Nov 19. Reference Source
25. Statistics Canada: The Daily – Population size and growth in Canada.2017 Feb 10. Reference Source
26. Turban JL, King D, Reisner SL, et al.: Psychological attempts to change a person’s gender identity from transgender to cisgender: Estimated prevalence across US states, 2015. Am. J. Public Health. 2019; 109(10): 1452–1454. PubMed Abstract | Publisher Full Text | Free Full Text
27. Born Perfect: Conversion Therapy Bans by U.S. State.2021 Oct 8. Reference Source
28. Green C: Geographic Information Systems and Public Health: Benefits and Challenges. National Collaborating Centre for Infectious Diseases. 2012; 37: 1–12.
29. Salway TJ, Morgan J, Ferlatte O, et al.: A systematic review of characteristics of nonprobability community venue samples of sexual minority individuals and associated methods for assessing selection bias. LGBT Health. 2019; 6(5): 205–215. PubMed Abstract | Publisher Full Text
30. Tiwana A, Salway T, Schillaci-Ventura J, et al.: Survey About “Conversion Therapy” in Canada. Zenodo. 2023. Publisher Full Text
31. Tiwana A, Salway T, Schillaci-Ventura J, et al.: Sensitivity analysis: ongoing and historical conversion therapy practices (CTPs) in Canada. Zenodo. 2023. Publisher Full Text

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Version 2

VERSION 2 PUBLISHED 18 Jul 2023

Author details Author details

¹ Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
² Department of Psychology, Simon Fraser University, Burnaby, British Columbia, Canada

Amrit Tiwana
Roles: Conceptualization, Data Curation, Formal Analysis, Methodology, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Travis Salway
Roles: Conceptualization, Formal Analysis, Funding Acquisition, Investigation, Methodology, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing

Julia Schillaci-Ventura
Roles: Data Curation, Methodology, Writing – Review & Editing

Sarah Watt
Roles: Conceptualization, Methodology, Writing – Review & Editing

Competing interests

No competing interests were disclosed.

Grant information

This study was supported by the Canadian Institutes of Health Research (FRN: PCS - 168193), Andrew Beckerman, and the Victoria Foundation. The funding sources did not play a role in the study design, the collection and analysis of data, the decision to publish or the preparation of the manuscript.
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Article Versions (2)

version 2

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Published: 15 Aug 2024, 12:844

https://doi.org/10.12688/f1000research.134292.2

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https://doi.org/10.12688/f1000research.134292.1

© 2024 Tiwana A et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Tiwana A, Salway T, Schillaci-Ventura J and Watt S. Geographic distribution of conversion therapy prevalence in Canada. Findings from a national cross-sectional survey, 2020 [version 2; peer review: 2 approved, 1 approved with reservations]. F1000Research 2024, 12:844 (https://doi.org/10.12688/f1000research.134292.2)

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ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested

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Version 2

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PUBLISHED 15 Aug 2024

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Reviewer Report 26 Aug 2024

Sean Mulcahy, La Trobe University, Victoria, Australia

Approved

https://doi.org/10.5256/f1000research.170215.r314339

The authors have well addressed the points raised in the initial peer review. In particular, the information on municipal bans is very helpful and could portend an interesting way forward in jurisdictions where federal and provincial legislative bans are not politically feasible.

There are still some limitations to this study that bear noting in addition to those already identified. Namely, the sample size is very small, being based on a study of 31 participants (though understanding the difficulty of attracting participants research of this kind), and a very proactive cohort making on average 4 reports of conversion therapy practices each (and up to 31). Another limitation of the survey method is that people have different conceptual understandings of what amounts to a conversion therapy practice and may report practices that do not amount to conversion therapy.

Obviously, further studies are needed to determine whether conversion practices are geographically specific, as flagged by the authors. Future studies could also usefully explore whether there have been any court judgments against conversion practices and the range of sentences that have been imposed.

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Human rights and law reform for LGBTIQA+ communities.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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Reviewer Report 20 Feb 2024

Travis Scheadler, The Ohio State University, Columbus, Ohio, USA

Approved with Reservations

https://doi.org/10.5256/f1000research.147338.r234548

This study aimed to estimate the spatial patterning of conversion therapy practices (CTPs) in Canada. Overall, the study is well-written and has important policy and research implications. There are a few notes (see below) that should be addressed to improve the quality of the manuscript. These are all relatively minor.

Please add a sentence clarifying what you mean by "tip of the iceberg." I understand this is minor, but can help ensure readers unfamiliar with CTPs understand exactly what is being conveyed.

Please make sure there is consistency in verb tense. The first sentence says "CTPs are" and the second says "It has" - determine whether CTPs are/is plural or singular. Be sure to check for consistency throughout the manuscript.

The first paragraph under "The harms of conversion therapy" is excellent! This is very succinct and straightforward. Great job!

Consider revising the first sentence in the second paragraph under "Attempts to ban conversion therapy." Changing "are widely discredited and denounced practices" to "have been banned in many parts of Canada" will smooth the transition between these paragraphs and help narrow down the problem to the specific purpose of this study. The beginning of this sentence currently seems more connected to the first half of the Introduction on the generalized harms of CTPs rather than the legislative bans in Canada.

Change was to were in the second sentence of the first paragraph under Measures.

Table 2 would be less wordy if columns 1 and 2 are switched. For instance, merge all the cells for Alberta to avoid repeating "Alberta" 11 times.

Change "conversion practices" to CTPs in the sentence that starts with "The following provinces/territories had <5 reports of conversion practices."

The figures are all great visualizations!

Delete or reword "lifetime and between the years 2010 and 2015, by US state" in the second paragraph of the Discussion. This part of the sentence is cumbersome and confusing to read. Also, in the following sentence, change "the findings from this study" to "the authors." Some readers may mistake "findings from this study" as findings from YOUR current study. Please also consider changing "continue to occur in every US state as recently as the period 2010 to 2015" to "continued to occur in every US state between 2010 and 2015." Then, consider the following revision for the last part of the sentence: "even though major US medical organizations have identified PACGI as ineffective and 20 states and more than 100 municipalities throughout the US have banned PACGI." These changes should improve the readability of this paragraph by offering more consistency in the different lists provided. Another note - 22 states have now banned licensed professionals from providing conversion therapy to minors. Additionally, please be sure to cite the correct sources. The 24th reference is related to the population size of Canada and is unrelated to PACGI in the United States. Be sure to check all references to make sure they are aligned. Note: this is why I marked "partly" to the first question about whether current literature is cited.

In the final paragraph before limitations - be careful not to undersell yourself. I appreciate the clarity around how to interpret the findings, but I also think there is room here for a call to action. Consider adding a paragraph - or even just a sentence or two - calling for bans against CTPs in the areas where it is most prevalent. I see that this was briefly mentioned in the Conclusion. I think there is room for it here as well.

Add a general sentence to start the limitations section. This can simply be "the present study is not without limitations" or some similar version of this. For the third limitation, add "especially given that some participants were recruited through word-of-mouth." This should help clarify a little more why this is a limitation.

Delete the term "underscore" in the second sentence under future research.

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: sport for social justice, LGBTQ+ activism and health, LGBTQ+ policies

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

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Author Response 15 Aug 2024

Amrit Tiwana, Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada

15 Aug 2024

Author Response

To clarify what we mean by “tip of the iceberg”, we have included a detailed version of the previous sentence on page 3: “CTPs are typically organized (i.e., structured activities) ... Continue reading To clarify what we mean by “tip of the iceberg”, we have included a detailed version of the previous sentence on page 3: “CTPs are typically organized (i.e., structured activities) and circumscribed (e.g., a certain number of sessions with a practitioner); these practices are, metaphorically, only the “tip of the iceberg”, representing visible and formally recognized forms of efforts to change LGBTQ2S+ identities.”

Thank you for pointing out the inconsistency in verb tense. We have reviewed the manuscript and ensured that the subject "CTPs" is consistently treated as a plural noun throughout. We have updated the verb tense to maintain consistency, so all instances now read "CTPs are" or "CTPs have."

We have changed the sentence accordingly so that it is more connected to the legislative bans in Canada rather than the first half of the introduction on the generalized harms of CTPs. This can be found on page 5: “Given that CTPs have been banned in many parts of Canada, many conversion therapy providers do not advertise themselves as “conversion therapists”.

We have changed “was” to “were” in the second sentence of the first paragraph under Measures.

Thank you for this suggestion regarding the format of Table 2. We discussed it as a team of authors and decided the current ordering—by date of enactment—makes it easy for the reader to see how the cumulative protections accrued over time; therefore, we have left the table as is.

We have changed “conversion practices” to “CTPs” on page 12: “The following provinces/territories had <5 reports of CTPs and therefore are not further interpreted: Yukon (55.75), PEI (7.00), and Newfoundland and Labrador (1.92). No data were reported regarding the prevalence of ongoing CTPs in the Northwest Territories and Nunavut.”

We have revised the second paragraph of the Discussion section to improve clarity and readability. We removed the phrase "lifetime and between the years 2010 and 2015, by US state" and rephrased it to better convey the intended meaning. Additionally, we replaced "the findings from this study" with "the authors" to avoid any potential confusion. The sentence now reads: "The authors explored this issue between 2010 and 2015 across US states, finding that PACGI continued to occur in every state between 2010 and 2015, even though major US medical organizations have identified PACGI as ineffective and 22 states and more than 100 municipalities throughout the US have banned PACGI." We also corrected the reference citations to ensure accuracy and alignment with the content. Thank you for this feedback.

We have incorporated your feedback using a few sentences in the last paragraph for the limitations. This can be found on page 13: “Despite this, our study emphasizes the urgent need for nationwide legislative bans against CTPs in Canada. Areas without bans continue to experience significantly higher prevalence rates, highlighting the ongoing harm inflicted on LGBTQ2S+ individuals. Comprehensive bans, along with rigorous enforcement and support for affected communities, are essential steps toward mitigating these harmful practices and promoting inclusive and affirming environments nationwide.”

We have added a sentence at the beginning of the paragraph on the limitations. This can be found on page 13: “The present study is not without limitations.”

The word “underscore” has been deleted. The sentence is now changed to “The results of this study should be confirmed and repeated with a larger sample size to ensure representativeness."
To clarify what we mean by “tip of the iceberg”, we have included a detailed version of the previous sentence on page 3: “CTPs are typically organized (i.e., structured activities) and circumscribed (e.g., a certain number of sessions with a practitioner); these practices are, metaphorically, only the “tip of the iceberg”, representing visible and formally recognized forms of efforts to change LGBTQ2S+ identities.”

Thank you for pointing out the inconsistency in verb tense. We have reviewed the manuscript and ensured that the subject "CTPs" is consistently treated as a plural noun throughout. We have updated the verb tense to maintain consistency, so all instances now read "CTPs are" or "CTPs have."

We have changed the sentence accordingly so that it is more connected to the legislative bans in Canada rather than the first half of the introduction on the generalized harms of CTPs. This can be found on page 5: “Given that CTPs have been banned in many parts of Canada, many conversion therapy providers do not advertise themselves as “conversion therapists”.

We have changed “was” to “were” in the second sentence of the first paragraph under Measures.

Thank you for this suggestion regarding the format of Table 2. We discussed it as a team of authors and decided the current ordering—by date of enactment—makes it easy for the reader to see how the cumulative protections accrued over time; therefore, we have left the table as is.

We have changed “conversion practices” to “CTPs” on page 12: “The following provinces/territories had <5 reports of CTPs and therefore are not further interpreted: Yukon (55.75), PEI (7.00), and Newfoundland and Labrador (1.92). No data were reported regarding the prevalence of ongoing CTPs in the Northwest Territories and Nunavut.”

We have revised the second paragraph of the Discussion section to improve clarity and readability. We removed the phrase "lifetime and between the years 2010 and 2015, by US state" and rephrased it to better convey the intended meaning. Additionally, we replaced "the findings from this study" with "the authors" to avoid any potential confusion. The sentence now reads: "The authors explored this issue between 2010 and 2015 across US states, finding that PACGI continued to occur in every state between 2010 and 2015, even though major US medical organizations have identified PACGI as ineffective and 22 states and more than 100 municipalities throughout the US have banned PACGI." We also corrected the reference citations to ensure accuracy and alignment with the content. Thank you for this feedback.

We have incorporated your feedback using a few sentences in the last paragraph for the limitations. This can be found on page 13: “Despite this, our study emphasizes the urgent need for nationwide legislative bans against CTPs in Canada. Areas without bans continue to experience significantly higher prevalence rates, highlighting the ongoing harm inflicted on LGBTQ2S+ individuals. Comprehensive bans, along with rigorous enforcement and support for affected communities, are essential steps toward mitigating these harmful practices and promoting inclusive and affirming environments nationwide.”

We have added a sentence at the beginning of the paragraph on the limitations. This can be found on page 13: “The present study is not without limitations.”

The word “underscore” has been deleted. The sentence is now changed to “The results of this study should be confirmed and repeated with a larger sample size to ensure representativeness."
Competing Interests: No competing interests were disclosed. Close
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COMMENTS ON THIS REPORT

Author Response 15 Aug 2024

Amrit Tiwana, Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada

15 Aug 2024

Author Response

To clarify what we mean by “tip of the iceberg”, we have included a detailed version of the previous sentence on page 3: “CTPs are typically organized (i.e., structured activities) ... Continue reading To clarify what we mean by “tip of the iceberg”, we have included a detailed version of the previous sentence on page 3: “CTPs are typically organized (i.e., structured activities) and circumscribed (e.g., a certain number of sessions with a practitioner); these practices are, metaphorically, only the “tip of the iceberg”, representing visible and formally recognized forms of efforts to change LGBTQ2S+ identities.”

Thank you for pointing out the inconsistency in verb tense. We have reviewed the manuscript and ensured that the subject "CTPs" is consistently treated as a plural noun throughout. We have updated the verb tense to maintain consistency, so all instances now read "CTPs are" or "CTPs have."

We have changed the sentence accordingly so that it is more connected to the legislative bans in Canada rather than the first half of the introduction on the generalized harms of CTPs. This can be found on page 5: “Given that CTPs have been banned in many parts of Canada, many conversion therapy providers do not advertise themselves as “conversion therapists”.

We have changed “was” to “were” in the second sentence of the first paragraph under Measures.

Thank you for this suggestion regarding the format of Table 2. We discussed it as a team of authors and decided the current ordering—by date of enactment—makes it easy for the reader to see how the cumulative protections accrued over time; therefore, we have left the table as is.

We have changed “conversion practices” to “CTPs” on page 12: “The following provinces/territories had <5 reports of CTPs and therefore are not further interpreted: Yukon (55.75), PEI (7.00), and Newfoundland and Labrador (1.92). No data were reported regarding the prevalence of ongoing CTPs in the Northwest Territories and Nunavut.”

We have revised the second paragraph of the Discussion section to improve clarity and readability. We removed the phrase "lifetime and between the years 2010 and 2015, by US state" and rephrased it to better convey the intended meaning. Additionally, we replaced "the findings from this study" with "the authors" to avoid any potential confusion. The sentence now reads: "The authors explored this issue between 2010 and 2015 across US states, finding that PACGI continued to occur in every state between 2010 and 2015, even though major US medical organizations have identified PACGI as ineffective and 22 states and more than 100 municipalities throughout the US have banned PACGI." We also corrected the reference citations to ensure accuracy and alignment with the content. Thank you for this feedback.

We have incorporated your feedback using a few sentences in the last paragraph for the limitations. This can be found on page 13: “Despite this, our study emphasizes the urgent need for nationwide legislative bans against CTPs in Canada. Areas without bans continue to experience significantly higher prevalence rates, highlighting the ongoing harm inflicted on LGBTQ2S+ individuals. Comprehensive bans, along with rigorous enforcement and support for affected communities, are essential steps toward mitigating these harmful practices and promoting inclusive and affirming environments nationwide.”

We have added a sentence at the beginning of the paragraph on the limitations. This can be found on page 13: “The present study is not without limitations.”

The word “underscore” has been deleted. The sentence is now changed to “The results of this study should be confirmed and repeated with a larger sample size to ensure representativeness."
To clarify what we mean by “tip of the iceberg”, we have included a detailed version of the previous sentence on page 3: “CTPs are typically organized (i.e., structured activities) and circumscribed (e.g., a certain number of sessions with a practitioner); these practices are, metaphorically, only the “tip of the iceberg”, representing visible and formally recognized forms of efforts to change LGBTQ2S+ identities.”

Thank you for pointing out the inconsistency in verb tense. We have reviewed the manuscript and ensured that the subject "CTPs" is consistently treated as a plural noun throughout. We have updated the verb tense to maintain consistency, so all instances now read "CTPs are" or "CTPs have."

We have changed the sentence accordingly so that it is more connected to the legislative bans in Canada rather than the first half of the introduction on the generalized harms of CTPs. This can be found on page 5: “Given that CTPs have been banned in many parts of Canada, many conversion therapy providers do not advertise themselves as “conversion therapists”.

We have changed “was” to “were” in the second sentence of the first paragraph under Measures.

Thank you for this suggestion regarding the format of Table 2. We discussed it as a team of authors and decided the current ordering—by date of enactment—makes it easy for the reader to see how the cumulative protections accrued over time; therefore, we have left the table as is.

We have changed “conversion practices” to “CTPs” on page 12: “The following provinces/territories had <5 reports of CTPs and therefore are not further interpreted: Yukon (55.75), PEI (7.00), and Newfoundland and Labrador (1.92). No data were reported regarding the prevalence of ongoing CTPs in the Northwest Territories and Nunavut.”

We have revised the second paragraph of the Discussion section to improve clarity and readability. We removed the phrase "lifetime and between the years 2010 and 2015, by US state" and rephrased it to better convey the intended meaning. Additionally, we replaced "the findings from this study" with "the authors" to avoid any potential confusion. The sentence now reads: "The authors explored this issue between 2010 and 2015 across US states, finding that PACGI continued to occur in every state between 2010 and 2015, even though major US medical organizations have identified PACGI as ineffective and 22 states and more than 100 municipalities throughout the US have banned PACGI." We also corrected the reference citations to ensure accuracy and alignment with the content. Thank you for this feedback.

We have incorporated your feedback using a few sentences in the last paragraph for the limitations. This can be found on page 13: “Despite this, our study emphasizes the urgent need for nationwide legislative bans against CTPs in Canada. Areas without bans continue to experience significantly higher prevalence rates, highlighting the ongoing harm inflicted on LGBTQ2S+ individuals. Comprehensive bans, along with rigorous enforcement and support for affected communities, are essential steps toward mitigating these harmful practices and promoting inclusive and affirming environments nationwide.”

We have added a sentence at the beginning of the paragraph on the limitations. This can be found on page 13: “The present study is not without limitations.”

The word “underscore” has been deleted. The sentence is now changed to “The results of this study should be confirmed and repeated with a larger sample size to ensure representativeness."
Competing Interests: No competing interests were disclosed. Close
Report a concern

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Reviewer Report 09 Feb 2024

Benjamin Harrell, Econ, Trinity University, San Antonio, Texas, USA

Approved

https://doi.org/10.5256/f1000research.147338.r234559

Summary: The study presents the results of a non-probabilistic survey of Canadian adults who either (a) have experienced conversion therapy practices (CTPs) or (b) know someone who has. Importantly, this study generates key knowledge about the geospatial distribution of CTPs across Canada. This is important context because not all territories and provinces ban CTPs, leaving important gaps in legal protections for sexual and gender minorities (SGM). The findings are stark: Only 55.1% of Canadians enjoy protections from CTP, with the highest prevalence of CTPs occurring in the west and the Atlantic regions. Similarly, the findings suggest that protections are imperfectly binding, these practices are still occurring in regions which ban them, albeit at much lower rates--in regions without bans, CTPs occur at 1.76 times the rate of regions WITH bans.

Assessment: This important study provides important context to the growing global literature around the prevalence, consequences, and harms of CTPs and other forms of sexual orientation and gender identity change efforts (SOGICE). The study also comes with key limitations. The most immediate limitation of the study is that statistics are derived from a small sample size. Prevalence rates could be biased by the relatively young sample (about 3/4 are younger than 50) and non-representativeness of provincial or territorial residence (there were no responses from Saskatchewan Manitoba, or the territories), Similarly, the sampling strategy (mostly Vancouver, BC based community organizations or CTP survivors) could bias the estimates in ways that are not clear. It could be the case that this survey underestimates the prevalence of CTP due to its under-representativeness of rural SGM, but it could also overestimate the prevalence of CTP due to its focus on survivors of CTP, especially since CTP is known to be correlated with suicidality.

Despite these limitations, which are both well-documented by authors, and contextualized as directions for future research, this study is a significant contribution to a fundamental question in this research space: WHERE is CTP happening, as much as to whom.

A note on data availability: While there is no data made available for replication of this study, the authors make a compelling case for non-inclusion. The data is inherently sensitive and many participants did not provide consent to share their data. However, the authors do provide instructions on how to acquire aggregated data sufficient to qualitatively replicate this study.

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

No source data required
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: I am an economist studying sexual and gender minority population health. I specialize in mental healthcare, health policy, and the demography of SGM people. In relation to this paper, I have presented work on the effects of CTP bans in the United States and their effects on suicidality and mental health.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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Reviewer Report 04 Oct 2023

Sean Mulcahy, La Trobe University, Victoria, Australia

Approved with Reservations

https://doi.org/10.5256/f1000research.147338.r211737

This is important research on the geographic distribution of conversion therapy practices in Canadian provinces and territories with and without a ban on these practices.

The article could be strengthened by addressing the following points.

First, what is the nature of bans in those jurisdictions which have them? For example, do they extend to trans/two spirit communities (as the Manitoba non-legislative ban appeared to only extend to sexual orientation)? Are they only focussed on clinical settings (for example, precluding conversations between a child and a parent)?

Second, what available information is there on enforcement of bans? For example, are there crime statistics or sentencing data available?
Third, what is the effect of municipal (as opposed to provincial or territorial) bans? In this respect, it would be useful to include a full list of municipalities that have enacted legislative bans (and the provinces or territories they are in), particularly given the research found that there were conversion therapy practices in, on average, about 7 municipalities in each province or territory identified.

Fourth, whilst the study lists limitations, some of these should be extended as noted. Per limitations 1 and 2, the sample size was indeed very small, being based on a study of 31 participants (though understanding the difficulty of attracting participants research of this kind), and a very proactive cohort making on average 4 reports of conversion therapy practices each (and up to 31). Per limitation 4, another limitation of the survey method is that people have different conceptual understandings of what amounts to a conversion therapy practice and may report practices that do not amount to conversion therapy. Some further limitations also need to be noted: (a) as the study states earlier, "it was not possible to determine whether the... reports were mutually exclusive" meaning that the same practice could have been reported multiple times thus over-emphasising the prevalence of conversion therapy practices in a particular province or territory; (b) conclusions about Prince Edward Island cannot be reached because it was excluded (as one of the "provinces/territories [that] had <5 reports of conversion practices and therefore are not further interpreted").

Fifth and finally, the study notes that "results from SN2019 did not find a difference in the prevalence of CTPs across provinces and territories in Canada." Obviously, this study challenges that finding, so it would be useful to articulate why SN2019 did not find a geographic difference and what the possible limitations of that study could be compared to this.

The study ends with strong conclusions and possible directions for future research, proving the utility and importance of research of this kind.

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Human rights and law reform for LGBTIQA+ communities.

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Author Response 15 Aug 2024

Amrit Tiwana, Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada

15 Aug 2024

Author Response

First, we have added the following explanatory text to the Introduction (see page 4): “This federal law defined CTP in relation to both sexual orientation and gender identity. While provincial/territorial ... Continue reading First, we have added the following explanatory text to the Introduction (see page 4): “This federal law defined CTP in relation to both sexual orientation and gender identity. While provincial/territorial bans have predominantly focused on clinical settings, the federal law applies to all settings, including those outside licensed healthcare. However, informal practices like parent-child conversations are typically not covered by these bans. Nonetheless, legislation represents an important milestone in the government’s commitment to protecting LGBTQ2S+ people.”

Second, to the best of our knowledge, there has been little to no enforcement of bans. Crime statistics are not yet available, though these could be reported in the future (e.g., by Statistics Canada). The absence of these data further motivates community surveys like the one we conducted. We have added the following line to the Introduction (see page 5): “Moreover, official data on enforcement of bans are absent, and many who experience CTP may choose not to disclose their experiences owing to feelings of shame.”

Third, we have included a list of municipalities with bans in Table 2. We have added detail regarding the typical mechanism of municipal bans on page 4: “Municipal bans typically operate through prohibition of CTP under bylaws governing the provision of business licenses.”

Fourth, we have included these in the limitations section on page 14: “Fifth, it was not possible to determine whether the reports were mutually exclusive. This means that the same practice could have been reported multiple times, potentially overemphasizing the prevalence of CTPs in a particular province or territory. Sixth, conclusions about certain regions, such as Prince Edward Island, cannot be reached because they were excluded from the analysis due to having fewer than five reports of CTPs. This exclusion could lead to an incomplete estimation of the prevalence and distribution of CTPs across Canada.”

Fifth, we have added why SN2019 did not find geographic differences and what the possible limitations of that study could be compared to ours. This new addition can be found on page 13: “On the other hand, the SN2019 study did not find a difference in the prevalence of CTPs across provinces and territories in Canada. The difference in findings between SN2019 and our study may be due to differences in survey methodologies or sample sizes, as our study used a more targeted approach to recruit participants with direct or indirect experiences of CTPs.”
First, we have added the following explanatory text to the Introduction (see page 4): “This federal law defined CTP in relation to both sexual orientation and gender identity. While provincial/territorial bans have predominantly focused on clinical settings, the federal law applies to all settings, including those outside licensed healthcare. However, informal practices like parent-child conversations are typically not covered by these bans. Nonetheless, legislation represents an important milestone in the government’s commitment to protecting LGBTQ2S+ people.”

Second, to the best of our knowledge, there has been little to no enforcement of bans. Crime statistics are not yet available, though these could be reported in the future (e.g., by Statistics Canada). The absence of these data further motivates community surveys like the one we conducted. We have added the following line to the Introduction (see page 5): “Moreover, official data on enforcement of bans are absent, and many who experience CTP may choose not to disclose their experiences owing to feelings of shame.”

Third, we have included a list of municipalities with bans in Table 2. We have added detail regarding the typical mechanism of municipal bans on page 4: “Municipal bans typically operate through prohibition of CTP under bylaws governing the provision of business licenses.”

Fourth, we have included these in the limitations section on page 14: “Fifth, it was not possible to determine whether the reports were mutually exclusive. This means that the same practice could have been reported multiple times, potentially overemphasizing the prevalence of CTPs in a particular province or territory. Sixth, conclusions about certain regions, such as Prince Edward Island, cannot be reached because they were excluded from the analysis due to having fewer than five reports of CTPs. This exclusion could lead to an incomplete estimation of the prevalence and distribution of CTPs across Canada.”

Fifth, we have added why SN2019 did not find geographic differences and what the possible limitations of that study could be compared to ours. This new addition can be found on page 13: “On the other hand, the SN2019 study did not find a difference in the prevalence of CTPs across provinces and territories in Canada. The difference in findings between SN2019 and our study may be due to differences in survey methodologies or sample sizes, as our study used a more targeted approach to recruit participants with direct or indirect experiences of CTPs.”
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Author Response 15 Aug 2024

Amrit Tiwana, Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada

15 Aug 2024

Author Response

First, we have added the following explanatory text to the Introduction (see page 4): “This federal law defined CTP in relation to both sexual orientation and gender identity. While provincial/territorial ... Continue reading First, we have added the following explanatory text to the Introduction (see page 4): “This federal law defined CTP in relation to both sexual orientation and gender identity. While provincial/territorial bans have predominantly focused on clinical settings, the federal law applies to all settings, including those outside licensed healthcare. However, informal practices like parent-child conversations are typically not covered by these bans. Nonetheless, legislation represents an important milestone in the government’s commitment to protecting LGBTQ2S+ people.”

Second, to the best of our knowledge, there has been little to no enforcement of bans. Crime statistics are not yet available, though these could be reported in the future (e.g., by Statistics Canada). The absence of these data further motivates community surveys like the one we conducted. We have added the following line to the Introduction (see page 5): “Moreover, official data on enforcement of bans are absent, and many who experience CTP may choose not to disclose their experiences owing to feelings of shame.”

Third, we have included a list of municipalities with bans in Table 2. We have added detail regarding the typical mechanism of municipal bans on page 4: “Municipal bans typically operate through prohibition of CTP under bylaws governing the provision of business licenses.”

Fourth, we have included these in the limitations section on page 14: “Fifth, it was not possible to determine whether the reports were mutually exclusive. This means that the same practice could have been reported multiple times, potentially overemphasizing the prevalence of CTPs in a particular province or territory. Sixth, conclusions about certain regions, such as Prince Edward Island, cannot be reached because they were excluded from the analysis due to having fewer than five reports of CTPs. This exclusion could lead to an incomplete estimation of the prevalence and distribution of CTPs across Canada.”

Fifth, we have added why SN2019 did not find geographic differences and what the possible limitations of that study could be compared to ours. This new addition can be found on page 13: “On the other hand, the SN2019 study did not find a difference in the prevalence of CTPs across provinces and territories in Canada. The difference in findings between SN2019 and our study may be due to differences in survey methodologies or sample sizes, as our study used a more targeted approach to recruit participants with direct or indirect experiences of CTPs.”
First, we have added the following explanatory text to the Introduction (see page 4): “This federal law defined CTP in relation to both sexual orientation and gender identity. While provincial/territorial bans have predominantly focused on clinical settings, the federal law applies to all settings, including those outside licensed healthcare. However, informal practices like parent-child conversations are typically not covered by these bans. Nonetheless, legislation represents an important milestone in the government’s commitment to protecting LGBTQ2S+ people.”

Second, to the best of our knowledge, there has been little to no enforcement of bans. Crime statistics are not yet available, though these could be reported in the future (e.g., by Statistics Canada). The absence of these data further motivates community surveys like the one we conducted. We have added the following line to the Introduction (see page 5): “Moreover, official data on enforcement of bans are absent, and many who experience CTP may choose not to disclose their experiences owing to feelings of shame.”

Third, we have included a list of municipalities with bans in Table 2. We have added detail regarding the typical mechanism of municipal bans on page 4: “Municipal bans typically operate through prohibition of CTP under bylaws governing the provision of business licenses.”

Fourth, we have included these in the limitations section on page 14: “Fifth, it was not possible to determine whether the reports were mutually exclusive. This means that the same practice could have been reported multiple times, potentially overemphasizing the prevalence of CTPs in a particular province or territory. Sixth, conclusions about certain regions, such as Prince Edward Island, cannot be reached because they were excluded from the analysis due to having fewer than five reports of CTPs. This exclusion could lead to an incomplete estimation of the prevalence and distribution of CTPs across Canada.”

Fifth, we have added why SN2019 did not find geographic differences and what the possible limitations of that study could be compared to ours. This new addition can be found on page 13: “On the other hand, the SN2019 study did not find a difference in the prevalence of CTPs across provinces and territories in Canada. The difference in findings between SN2019 and our study may be due to differences in survey methodologies or sample sizes, as our study used a more targeted approach to recruit participants with direct or indirect experiences of CTPs.”
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Sean Mulcahy, La Trobe University, Victoria, Australia
Benjamin Harrell, Trinity University, San Antonio, USA
Travis Scheadler, The Ohio State University, Columbus, USA

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26 Aug 2024 | for Version 2

Sean Mulcahy, La Trobe University, Victoria, Australia

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Approved

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No competing interests were disclosed.

Reviewer Expertise

Human rights and law reform for LGBTIQA+ communities.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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20 Feb 2024 | for Version 1

Travis Scheadler, The Ohio State University, Columbus, Ohio, USA

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Approved With Reservations

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

sport for social justice, LGBTQ+ activism and health, LGBTQ+ policies

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Author Response

15 Aug 2024

Amrit Tiwana, Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada

To clarify what we mean by “tip of the iceberg”, we have included a detailed version of the previous sentence on page 3: “CTPs are typically organized (i.e., structured activities) and circumscribed (e.g., a certain number of sessions with a practitioner); these practices are, metaphorically, only the “tip of the iceberg”, representing visible and formally recognized forms of efforts to change LGBTQ2S+ identities.”

Thank you for pointing out the inconsistency in verb tense. We have reviewed the manuscript and ensured that the subject "CTPs" is consistently treated as a plural noun throughout. We have updated the verb tense to maintain consistency, so all instances now read "CTPs are" or "CTPs have."

We have changed the sentence accordingly so that it is more connected to the legislative bans in Canada rather than the first half of the introduction on the generalized harms of CTPs. This can be found on page 5: “Given that CTPs have been banned in many parts of Canada, many conversion therapy providers do not advertise themselves as “conversion therapists”.

We have changed “was” to “were” in the second sentence of the first paragraph under Measures.

Thank you for this suggestion regarding the format of Table 2. We discussed it as a team of authors and decided the current ordering—by date of enactment—makes it easy for the reader to see how the cumulative protections accrued over time; therefore, we have left the table as is.

We have changed “conversion practices” to “CTPs” on page 12: “The following provinces/territories had <5 reports of CTPs and therefore are not further interpreted: Yukon (55.75), PEI (7.00), and Newfoundland and Labrador (1.92). No data were reported regarding the prevalence of ongoing CTPs in the Northwest Territories and Nunavut.”

We have revised the second paragraph of the Discussion section to improve clarity and readability. We removed the phrase "lifetime and between the years 2010 and 2015, by US state" and rephrased it to better convey the intended meaning. Additionally, we replaced "the findings from this study" with "the authors" to avoid any potential confusion. The sentence now reads: "The authors explored this issue between 2010 and 2015 across US states, finding that PACGI continued to occur in every state between 2010 and 2015, even though major US medical organizations have identified PACGI as ineffective and 22 states and more than 100 municipalities throughout the US have banned PACGI." We also corrected the reference citations to ensure accuracy and alignment with the content. Thank you for this feedback.

We have incorporated your feedback using a few sentences in the last paragraph for the limitations. This can be found on page 13: “Despite this, our study emphasizes the urgent need for nationwide legislative bans against CTPs in Canada. Areas without bans continue to experience significantly higher prevalence rates, highlighting the ongoing harm inflicted on LGBTQ2S+ individuals. Comprehensive bans, along with rigorous enforcement and support for affected communities, are essential steps toward mitigating these harmful practices and promoting inclusive and affirming environments nationwide.”

We have added a sentence at the beginning of the paragraph on the limitations. This can be found on page 13: “The present study is not without limitations.”

The word “underscore” has been deleted. The sentence is now changed to “The results of this study should be confirmed and repeated with a larger sample size to ensure representativeness."

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09 Feb 2024 | for Version 1

Benjamin Harrell, Econ, Trinity University, San Antonio, Texas, USA

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Approved

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

No source data required
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

I am an economist studying sexual and gender minority population health. I specialize in mental healthcare, health policy, and the demography of SGM people. In relation to this paper, I have presented work on the effects of CTP bans in the United States and their effects on suicidality and mental health.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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04 Oct 2023 | for Version 1

Sean Mulcahy, La Trobe University, Victoria, Australia

21 Views Cite this report Responses(1)

Approved With Reservations

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Human rights and law reform for LGBTIQA+ communities.

Respond to this report

Responses (1)

Author Response

15 Aug 2024

Amrit Tiwana, Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada

First, we have added the following explanatory text to the Introduction (see page 4): “This federal law defined CTP in relation to both sexual orientation and gender identity. While provincial/territorial bans have predominantly focused on clinical settings, the federal law applies to all settings, including those outside licensed healthcare. However, informal practices like parent-child conversations are typically not covered by these bans. Nonetheless, legislation represents an important milestone in the government’s commitment to protecting LGBTQ2S+ people.”

Second, to the best of our knowledge, there has been little to no enforcement of bans. Crime statistics are not yet available, though these could be reported in the future (e.g., by Statistics Canada). The absence of these data further motivates community surveys like the one we conducted. We have added the following line to the Introduction (see page 5): “Moreover, official data on enforcement of bans are absent, and many who experience CTP may choose not to disclose their experiences owing to feelings of shame.”

Third, we have included a list of municipalities with bans in Table 2. We have added detail regarding the typical mechanism of municipal bans on page 4: “Municipal bans typically operate through prohibition of CTP under bylaws governing the provision of business licenses.”

Fourth, we have included these in the limitations section on page 14: “Fifth, it was not possible to determine whether the reports were mutually exclusive. This means that the same practice could have been reported multiple times, potentially overemphasizing the prevalence of CTPs in a particular province or territory. Sixth, conclusions about certain regions, such as Prince Edward Island, cannot be reached because they were excluded from the analysis due to having fewer than five reports of CTPs. This exclusion could lead to an incomplete estimation of the prevalence and distribution of CTPs across Canada.”

Fifth, we have added why SN2019 did not find geographic differences and what the possible limitations of that study could be compared to ours. This new addition can be found on page 13: “On the other hand, the SN2019 study did not find a difference in the prevalence of CTPs across provinces and territories in Canada. The difference in findings between SN2019 and our study may be due to differences in survey methodologies or sample sizes, as our study used a more targeted approach to recruit participants with direct or indirect experiences of CTPs.”

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Competing Interests

No competing interests were disclosed.

Alongside their report, reviewers assign a status to the article:

Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested

Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.

Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions

[1] 1. Bishop A: The Global Reach of So-Called Conversion Therapy. OutRight Action International; 2019. Reference Source

[2] 2. Ashley F: Model law – prohibiting reparative practices. SSRN Electron. J. 2019. Publisher Full Text

[3] 3. Centre for Gender and Sexual Health Equity: Ending conversion therapy in Canada: Survivors, community leaders, researchers, and allies address the current and future states of sexual orientation and gender identity and expression change efforts.2020 Feb 18. Reference Source

[4] 4. The Trevor Project: About Conversion Therapy.2020 Dec 20. Reference Source

[5] 5. Kinitz DJ, Goodyear T, Dromer E, et al.: “Conversion therapy” experiences in their social contexts: A qualitative study of sexual orientation and gender identity and expression change efforts in Canada: Les Expériences de “thérapie de conversion” dans leur contexte social: Une étude qualitative des efforts de changement de l’orientation sexuelle, de l’identité de genre et de l’expression de genre au Canada. Can. J. Psychiatr. 2021; 67: 441–451. Publisher Full Text

[6] 6. Adamson TM, Wallach S, Garner A, et al.: The global state of conversion therapy - a preliminary report and current Evidence Brief.2020. Publisher Full Text

[7] 7. Karten EY, Wade JC: Sexual orientation change efforts in men: A client perspective. J. Mens Stud. 2010; 18(1): 84–102. Publisher Full Text

[8] 8. Wells K: Conversion therapy in Canada: A guide for legislative action. Revised Edition.MacEwan University; 2020. Reference Source

[9] 9. The Human Rights Campaign: The lies and dangers of “conversion therapy”.Reference Source

[10] 10. Salway T, Ferlatte O, Gesink D, et al.: Prevalence of exposure to sexual orientation change efforts and associated sociodemographic characteristics and psychosocial health outcomes among Canadian Sexual Minority men. Can. J. Psychiatr. 2020; 65(7): 502–509. PubMed Abstract | Publisher Full Text | Free Full Text

[11] 11. Green AE, Price-Feeney M, Dorison SH, et al.: Self-reported conversion efforts and suicidality among US LGBTQ youths and young adults, 2018. Am. J. Public Health. 2020; 110(8): 1221–1227. PubMed Abstract | Publisher Full Text | Free Full Text

[12] 12. Meyer IH: Prejudice, social stress, and Mental Health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychol. Bull. 2003; 129(5): 674–697. PubMed Abstract | Publisher Full Text | Free Full Text

[13] 13. Rich AJ, Salway T, Scheim A, et al.: Sexual minority stress theory: Remembering and honoring the work of Virginia brooks. LGBT Health. 2020; 7(3): 124–127. PubMed Abstract | Publisher Full Text

[14] 14. Hatzenbuehler ML: How does sexual minority stigma “get under the skin”? A psychological mediation framework. Psychol. Bull. 2009; 135(5): 707–730. PubMed Abstract | Publisher Full Text | Free Full Text

[15] 15. Blosnich JR, Henderson ER, Coulter RW, et al.: Sexual orientation change efforts, adverse childhood experiences, and suicide ideation and attempt among sexual minority adults, United States, 2016–2018. Am. J. Public Health. 2020; 110(7): 1024–1030. Publisher Full Text

[16] 16. The Trans PULSE Canada Team: QuickStat #1 - Conversion Therapy.2019 Dec 12. Reference Source

[17] 17. Salway T, Juwono S, Klassen B, et al.: Experiences with sexual orientation and gender identity conversion therapy practices among sexual minority men in Canada, 2019–2020. PLoS One. 2021; 16(6): e0252539. PubMed Abstract | Publisher Full Text | Free Full Text

[18] 18. Wells K: Legislation Map. No Conversion Canada.Reference Source

[19] 19. Wells K: Conversion therapy in Canada: The roles and responsibilities of municipalities. Edmonton, AB: MacEwan University; 2019.

[20] 20. Brush J: Conversion Ministries and Ex-Gay Ministries. Ohio Psychological Association; 2021 Jan 29. Reference Source

[21] 21. Tiwana A: Identifying harmful “conversion therapy” practices in all its forms. MindMapBC; 2021 Oct 2. Reference Source

[22] 22. Goodyear T, Kinitz DJ, Dromer E, et al.: “They want you to kill your inner queer but somehow leave the human alive”: Delineating the impacts of sexual orientation and gender identity and expression change efforts. J. Sex Res. 2021; 59: 599–609. Publisher Full Text

[23] 23. Tiwana A, Salway T, Schillaci-Ventura J, et al.: Geographic distribution of conversion therapy prevalence in Canada. MedRxiv. 2022. Publisher Full Text

[24] 24. Statistics Canada: 2016 Census Boundary Files.2019 Nov 19. Reference Source

[25] 25. Statistics Canada: The Daily – Population size and growth in Canada.2017 Feb 10. Reference Source

[26] 26. Turban JL, King D, Reisner SL, et al.: Psychological attempts to change a person’s gender identity from transgender to cisgender: Estimated prevalence across US states, 2015. Am. J. Public Health. 2019; 109(10): 1452–1454. PubMed Abstract | Publisher Full Text | Free Full Text

[27] 27. Born Perfect: Conversion Therapy Bans by U.S. State.2021 Oct 8. Reference Source

[28] 28. Green C: Geographic Information Systems and Public Health: Benefits and Challenges. National Collaborating Centre for Infectious Diseases. 2012; 37: 1–12.

[29] 29. Salway TJ, Morgan J, Ferlatte O, et al.: A systematic review of characteristics of nonprobability community venue samples of sexual minority individuals and associated methods for assessing selection bias. LGBT Health. 2019; 6(5): 205–215. PubMed Abstract | Publisher Full Text

[30] 30. Tiwana A, Salway T, Schillaci-Ventura J, et al.: Survey About “Conversion Therapy” in Canada. Zenodo. 2023. Publisher Full Text

[31] 31. Tiwana A, Salway T, Schillaci-Ventura J, et al.: Sensitivity analysis: ongoing and historical conversion therapy practices (CTPs) in Canada. Zenodo. 2023. Publisher Full Text

Geographic distribution of conversion therapy prevalence in Canada. Findings from a national cross-sectional survey, 2020

Abstract

Keywords

Revised Amendments from Version 1

Introduction

The harms of conversion therapy

Prevalence of conversion therapy

Attempts to ban conversion therapy

The purpose of this research

Methods

Study design

Participants

Measures

Analyses

Results

Table 1. Demographic characteristics of participants who report knowing ongoing or historical conversion therapy practices in Canada, (N = 31).

Table 2. List of the dates of legislative bans passed on conversion therapy practices (CTPs) in Canadian municipalities, provinces, and territories.

Figure 1. Municipal, provincial, and territorial legislative bans on conversion therapy practices (CTPs) in Canada as of August 2020.

Table 3. Prevalence of ongoing conversion therapy practices (CTPs) in Canadian provinces and territories with bans versus without bans at the provincial level.

Figure 2. A heat map of the prevalence of reported ongoing conversion therapy practices (CTPs) in Canada using count data (N = 99).

Figure 3. Prevalence of ongoing reported conversion therapy practices (CTPs) divided by 1,000,000 population per province/territory (N = 119).

Discussion

Limitations

Future research

Conclusion

Ethical considerations

Data availability

Underlying data

Extended data

Reporting guidelines

Acknowledgements

References

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