Lifetime Exposure to Conversion Therapy and Psychosocial Health Among Midlife and Older Adult Men Who Have Sex With Men

Sexual Orientation Change Efforts Among LGBT+ People of Kerala: Prevalence, Correlates, and Mental Health Aspects

Sexual Orientation Change Efforts (SOCE) have been reported worldwide and have adverse psychiatric consequences. However, no data are available for India or Kerala. We assessed the prevalence of SOCE, its characteristics, and mental health aspects among LGBT+ individuals in Kerala. This cross-sectional survey used snowball sampling. An online questionnaire collected sociodemographic information and history and characteristics of SOCE. Religiosity and SOCE-associated distress were evaluated using 6-point Likert scales. Patient Health Questionnaire (PHQ-9) screened for depressive symptoms; its ninth question assessed death wishes and self-harm thoughts. Generalized Anxiety Disorder Assessment (GAD-7) screened for anxiety symptoms. Participants' (n = 130) mean age was 26.80 ± 7.12 years. Most common biological sex (63.1%) and gender identity (50.8%) were male, and sexual orientation was gay(42.3%). Prevalence of SOCE was 45.4%. In SOCE group, 39% reported very severe distress. SOCE was most commonly self-prompted (47.5%), performed through psychotherapy (28.8%), and performed by doctors (28.8%). SOCE group had significantly higher religiosity scores (t = 2.61, p = .01). Among cisgender men, 48.48% had SOCE history, against 28.57% among cisgender women (χ2 = 3.19, p = .07). SOCE is highly prevalent among the LGBT+ community in Kerala, with high associated distress. Multi-level approaches are necessary to mitigate this problem.

Inequities in Conversion Practice Exposure at the Intersection of Ethnoracial and Gender Identities

Objectives. To examine inequities in conversion practice exposure across intersections of ethnoracial groups and gender identity in the United States. Methods. Data were obtained from The Population Research in Identity and Disparities for Equality Study of sexual and gender minority people from 2019 to 2021 (n = 9274). We considered 3 outcomes: lifetime exposure, age of first exposure, and period between first and last exposure among those exposed to conversion practices. We used log-binomial, Cox proportional hazards, and negative binomial models to examine inequities by ethnoracial groups and gender identity adjusting for confounders. We considered additive interaction. Results. Conversion practice prevalence was highest among minoritized ethnoracial transgender and nonbinary participants (TNB; 8.6%). Compared with White cisgender participants, minoritized ethnoracial TNB participants had twice the prevalence (prevalence ratio = 2.16; 95% confidence interval [CI] = 1.62, 2.86) and risk (hazard ratio = 2.04; 95% CI = 1.51, 2.69) of conversion practice exposure. Furthermore, there was evidence of a positive additive interaction for age of first exposure. Conclusions. Minoritized ethnoracial TNB participants were most likely to recall experiencing conversion practices. Public Health Implications. Policies banning conversion practices may reduce the disproportionate burden experienced by minoritized ethnoracial TNB participants. (Am J Public Health. 2024;114(4):424-434. https://doi.org/10.2105/AJPH.2024.307580).

The Relationship Between Posttraumatic Stress Disorder and Alcohol Misuse and Smoking Among Aging Men Who Have Sex With Men: No Evidence of Exercise or Volunteering Impact

OBJECTIVES

To determine if the association between posttraumatic stress disorder (PTSD) and substance use (alcohol misuse or smoking tobacco) is mediated/moderated by exercise or volunteering among aging (≥40 years) men who have sex with men (MSM), and if this mediation/moderation differs by HIV serostatus.

METHODS

Multicenter AIDS Cohort Study data were used. Three datasets with PTSD measured during different time periods (10/1/2017-3/31/2018, 898 men; 4/1/2018-9/30/2018, 890 men; 10/1/2018-3/31/2019, 895 men) were analyzed. Longitudinal mediation analyses estimated the mediation effect of exercise and volunteering on the outcomes.

RESULTS

Nine percent of MSM had evidence of PTSD. There was no statistically significant mediation effect of exercise or volunteering regardless of substance use outcome. The odds of smoking at a future visit among MSM with PTSD were approximately double those of MSM without PTSD. Results did not differ by HIV serostatus.

DISCUSSION

There is a particular need for effective smoking cessation interventions for aging MSM with PTSD.

Grit is associated with psychological health among older sexual minority men

Objectives: Studies have shown that grit-defined as perseverance and passion for achieving one's long-term goals-is associated with improved health outcomes, including lower levels of psychological distress. However, the psychometric properties of the original Grit Scale (Grit-O Scale) has not been validated among sexual minority men (SMM). The present study aimed to validate the Grit-O Scale among a sample of older SMM and assess the relationships between the Grit-O Scale factors and symptoms of psychological distress.Method: We used data from a single visit of participants in the Multicenter AIDS Cohort Study (MACS) Healthy Aging longitudinal study. The sample included 981 older SMM (mean age = 61, SD = 8.5) with and without HIV. We conducted confirmatory factor analysis (CFA) to identify the two factors of the Grit-O Scale: consistency of interest and perseverance of effort. We also conducted a latent profile analysis (LPA) to identify distinct profiles of psychological distress from self-reported scales of depression, anxiety, and perceived stress.Results:The Grit-O Scale showed acceptable reliability estimates for the items with Cronbach's alpha reliability coefficients ranging from 0.77 to 0.82. The CFA identified the two factors of the Grit-O Scale with acceptable model fit (root mean square error of approximation = 0.058 [95% CI = 0.050, 0.067], comparative fit index = 0.95, Tucker-Lewis Index = 0.93, standardized root mean square residual = 0.07). The LPA yielded three mutually exclusive profiles of psychological distress (profile 1: low stress, anxiety, and depression; profile 2: high stress and depression and low anxiety; and profile 3: high stress, anxiety, and depression). In adjusted multinominal logistic regression analysis, we found that both higher levels of consistency of interest and perseverance of effort factors of the Grit-O Scale were significantly associated with decreased odds of being in profiles 2 and 3 compared with being in profile 1.Conclusion: Our findings support the use of the Grit-O Scale among older SMM. Grit factors could explain variability in the negative psychological symptoms among older SMM and warrant further investigation.Supplemental data for this article is available online at http://dx.doi.org/10.1080/13607863.2022.2032594.

Sexual Orientation Change Efforts Do Not Increase Suicide: Correcting a False Research Narrative

Sexual orientation change efforts (SOCEs) signify activities designed to change or reduce homosexual orientation. Recent studies have claimed that such therapies increase suicide risk by showing positive associations between SOCE and lifetime suicidality, without excluding behavior that pre-dated SOCE. In this way, Blosnich et al.'s (2020) recent analysis of a national probability sample of 1518 sexual minority persons concluded that SOCE "may compound or create…suicidal ideation and suicide attempts" but after correcting for pre-existing suicidality, SOCE was not positively associated with any form of suicidality. For suicidal ideation, Blosnich et al. reported an adjusted odds ratio (AOR) of 1.92 (95% CI 1.01-3.64); the corrected AOR was .44 (.20-.94). For suicide planning, Blosnich et al.'s AOR was 1.75 (1.01-3.06); corrected was .60 (.32-1.14). For suicide attempts, Blosnich et al.'s AOR was 1.75 (.99-3.08); corrected was .74 (.36-1.43). Undergoing SOCE after expressing suicidal behavior reduced subsequent suicide attempts from 72 to 80%, compared to those not undergoing SOCE, when SOCE followed a prior expression of suicidal ideation (AOR .17, .05-.55), planning (AOR .13, .04-.45) or intention (AOR .10, .03-.30); however, SOCE following an initial suicide attempt did not significantly reduce further attempts. By violating the principle that a cause cannot occur after an effect, Blosnich et al. misstated the correct conclusion. Experiencing SOCE does not result in higher suicidality, as they claim, and may sharply reduce subsequent suicide attempts. Restrictions on SOCE will not reduce suicidal risk among sexual minorities and may deprive them of an important resource for reducing suicide attempts.

Religiosity and Conversion Therapy is Associated with Psychosocial Health Problems among Sexual Minority Men (SMM) in Nigeria

We investigated the associations between social marginalization, psychosocial health, and religiosity among sexual minority men (SMM) in Nigeria (N = 406). We conducted bivariate and multivariable logistic regression. Factors associated with reporting a history of conversion therapy at a religious institution were: being HIV positive, having depressive symptoms, reporting suicide thoughts, and reporting inability to access medical care. Factors associated with increased odds of agreeing that sex between two men was a sin were: residing in Plateau, being Muslim, and higher levels of internalized homophobia. Our findings support the need for LGBT-affirming religious doctrine, which has implications for the health of LGBT communities.

Switching to Non-daily Pre-exposure Prophylaxis Among Gay and Bisexual Men in Australia: Implications for Improving Knowledge, Safety, and Uptake

INTRODUCTION

Preexposure prophylaxis (PrEP) dosing options such as event-driven PrEP hold promise to increase PrEP uptake among gay, bisexual, and queer men (GBQM), but their impacts have not yet been realized and uptake by GBQM suitable for PrEP remains slow in countries where it is only considered an alternative option to daily PrEP.

METHODS

We conducted semi-structured interviews between June 2020 and February 2021 with 40 GBQM in Australia to understand PrEP dosing behaviors, knowledge, and preferences.

RESULTS

All participants commenced PrEP daily; 35% had ever switched to non-daily PrEP, mostly taking it event-driven. GBQM who preferred non-daily PrEP had infrequent or predictable sex, were concerned about cost given infrequency of sex, and/or wanted to minimize unnecessary drug exposure. Accurate knowledge of event-driven PrEP was poor. However, reflecting concepts underpinning critical pedagogy, having accurate knowledge was supported by access to consistent messaging across clinical, social, community, and public settings. Several participants who switched to event-driven PrEP had condomless sex events in which they were unable to adhere to pills due to unanticipated sex.

CONCLUSIONS AND POLICY IMPLICATIONS

Implementation of comprehensive and consistent education about correct dosing for event-driven PrEP across multiple settings is needed to ensure increased uptake and safe use. GBQM require messaging about non-condom based HIV prevention strategies when they cannot access daily or event-driven PrEP.

Humanistic and Economic Burden of Conversion Therapy Among LGBTQ Youths in the United States

IMPORTANCE

Sexual orientation and gender identity change efforts (SOGICE), also called conversion therapy, is a discredited practice attempting to convert lesbian, gay, bisexual, transgender, queer, or questioning (LGBTQ) individuals to be heterosexual and/or cisgender.

OBJECTIVES

To identify and synthesize evidence on the humanistic and economic consequences of SOGICE among LGBTQ youths in the US.

DESIGN, SETTING, AND PARTICIPANTS

This study, conducted from December 1, 2020, to February 15, 2021, included a systematic literature review and economic evaluation. The literature review analyzed published evidence on SOGICE among LGBTQ individuals of any age. The economic model evaluated the use of SOGICE vs no intervention, affirmative therapy vs no intervention, and affirmative therapy vs SOGICE to estimate the costs and adverse outcomes for each scenario and to assess the overall US economic burden of SOGICE. Published literature and public sources were used to estimate the number of LGBTQ youths exposed to SOGICE, the types of therapy received, and the associated adverse events (anxiety, severe psychological distress, depression, alcohol or substance abuse, suicide attempts, and fatalities).

EXPOSURES

SOGICE (licensed or religion-based practitioners) or affirmative therapy (licensed practitioners).

MAIN OUTCOMES AND MEASURES

Total incremental costs and quality-adjusted life-years (QALYs) vs no intervention and total economic burden of SOGICE.

RESULTS

Among 28 published studies, which included 190 695 LGBTQ individuals, 12% (range, 7%-23%) of youths experienced SOGICE, initiated at a mean age of 25 years (range, 5-58 years), with a mean (SD) duration of 26 (29) months. At least 2 types of SOGICE were administered to 43% of recipients. Relative to LGBTQ individuals who did not undergo SOGICE, recipients experienced serious psychological distress (47% vs 34%), depression (65% vs 27%), substance abuse (67% vs 50%), and attempted suicide (58% vs 39%). In the economic analysis, over a lifetime horizon with a 3% annual discount rate, the base-case model estimated additional $97 985 lifetime costs per individual, with SOGICE associated with 1.61 QALYs lost vs no intervention; affirmative therapy yielded cost savings of $40 329 with 0.93 QALYs gained vs no intervention. With an estimated 508 892 youths at risk for SOGICE in 2021, the total annual cost of SOGICE is estimated at $650.16 million (2021 US dollars), with associated harms totaling an economic burden of $9.23 billion.

CONCLUSIONS AND RELEVANCE

This economic evaluation study suggests that there is a high economic burden and high societal costs associated with SOGICE and identifies additional research questions regarding the roles of private and public funding in supporting this harmful practice.

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

Background

Despite greater acceptance of sexual and gender diversity and the scientific consensus that same-gender attraction, creative gender expression, and transness are not mental illnesses, LGBTQI2+ persons are still commonly told that they can or should change their sexual orientation, gender identity, or gender expression (SOGIE). The aim of this study was to describe the prevalence of SOGIE conversion efforts, including their sociodemographic correlates, among LGBTQI2+ persons.

Methods

Using community-based sampling, we assessed SOGIE conversion attempts and involvement in conversion services of 3,261 LGBTQI2+ persons aged 18 years and older in Quebec, Canada.

Results

A quarter of respondents experienced SOGIE conversion attempts, and fewer than 5% were involved in conversion services. Over half of those who were involved in SOGIE conversion services consented to them, but the services’ goals were made clear and explicit to only 55% and 30% of those who engaged in SO and GIE conversion, respectively. The results also suggest that family plays a key role in SOGIE conversion attempts and services utilization, and that indigenous, intersex, transgender, non-binary, and asexual persons, people of colour, as well as individuals whose sexual orientation is not monosexual (i.e., bisexual, pansexual) were more likely to have been exposed to conversion attempts and involved in conversion services.

Conclusions

This study found that the prevalence of conversion efforts is substantial. Interventions to protect LGBTQI2+ people from such attempts should focus not only on legal bans, but also on supporting families who need to be counseled in accepting sexual and gender diversity. Health professionals need to be adequately trained in LGBTQI2+ affirmative approaches. Religious therapists should consult with colleagues and undergo supervision to ensure that their religious beliefs do not interfere with their practice.

Absence of Behavioral Harm Following Non-efficacious Sexual Orientation Change Efforts: A Retrospective Study of United States Sexual Minority Adults, 2016–2018

Background

Do sexual minority persons who have undergone unsuccessful sexual orientation change efforts (SOCE) suffer subsequent psychological or social harm from the attempt? Previous studies have conflated present and past, even pre-SOCE, harm in addressing this question. This study attempts, for the first time, to isolate and examine the question of current psychosocial harm for former SOCE participants among sexual minorities in representative population data.

Method

Using nationally representative data (n = 1,518) across three cohorts of sexual minorities (centered in 1969, 1987, and 2003) in the United States (U.S.), persons exposed to SOCE were compared with the remainder not exposed to SOCE on two measures of internal distress—psychological distress (Kessler scale) and current mental health—and seven measures of behavioral harm: substance abuse (DUDIT); alcohol dependence (AUDIT-C); self-harm; suicide ideation; suicide planning; suicide intentions; and suicide attempts.

Results

The SOCE group was statistically indistinguishable from the non-SOCE group on any measure of harm. For behavioral harm, risk ratios were 0.97–1.02. Harm was equivalent for the two groups despite the SOCE group having experienced higher lifetime and current minority stress, greater childhood adversity, and lower socioeconomic status. Logistic regression models that adjusted for these differences suggest that SOCE exposure reduced the effect of minority stress and childhood adversity for suicide attempts, although this effect did not fully account for the equivalence between the SOCE and non-SOCE groups.

Conclusion

Despite higher exposure to factors predicting behavioral harm—minority stress, childhood adversity, and lower socioeconomic background—sexual minority persons who had undergone failed SOCE therapy did not suffer higher psychological or social harm. Concerns to restrict or ban SOCE due to elevated harm are unfounded. Further study is needed to clarify the reasons for the absence of harm from SOCE.

The Effect of Discrimination and Resilience on Depressive Symptoms among Middle-Aged and Older Men who have Sex with Men

This study investigated if homophobic and racist discrimination increased depressive symptoms among 960 middle-aged and older men who have sex with men (MSM) and how resilience moderated these relationships. We used five waves of longitudinal data from the Healthy Aging sub-study of the Multicenter AIDS Cohort Study (MACS). We used linear regression analyses to model depressive symptoms as a function of discrimination. We used linear mixed analyses to model changes in mean resilience scores across visits. We used linear regression analyses to model depressive symptoms as a function of changes in resilience and to test the moderation effects of resilience on the relationship between discrimination and depressive symptoms. The models accounted for repeated measures of resilience. Men who experienced external and internal homophobia had greater depressive symptoms (β: 2.08; 95% Confidence Interval: 0.65, 3.51; β: 1.60; 95% Confidence Interval: 0.76, 2.44). Men experienced significant changes in mean resilience levels across visits (F = 2.84, p = 0.02). Men with a greater positive change in resilience had lower depressive symptoms (β: -0.95; 95% Confidence Interval: -1.47, -0.43). Men with higher average resilience levels had lower depressive symptoms (β: -5.08; 95% Confidence Interval: -5.68, -4.49). Men's resilience did not moderate the relationship between homophobia and depressive symptoms. Significant associations of external and internal homophobia with greater depressive symptoms present targets for future research and interventions among middle-aged and older MSM. Significant associations of average and positive changes in resilience with lower depressive symptoms provide aims for future research and interventions with this population.

Absence of Behavioral Harm Following Non-efficacious Sexual Orientation Change Efforts: A Retrospective Study of United States Sexual Minority Adults, 2016-2018

BACKGROUND

Do sexual minority persons who have undergone unsuccessful sexual orientation change efforts (SOCE) suffer subsequent psychological or social harm from the attempt? Previous studies have conflated present and past, even pre-SOCE, harm in addressing this question. This study attempts, for the first time, to isolate and examine the question of current psychosocial harm for former SOCE participants among sexual minorities in representative population data.

METHOD

Using nationally representative data (n = 1,518) across three cohorts of sexual minorities (centered in 1969, 1987, and 2003) in the United States (U.S.), persons exposed to SOCE were compared with the remainder not exposed to SOCE on two measures of internal distress-psychological distress (Kessler scale) and current mental health-and seven measures of behavioral harm: substance abuse (DUDIT); alcohol dependence (AUDIT-C); self-harm; suicide ideation; suicide planning; suicide intentions; and suicide attempts.

RESULTS

The SOCE group was statistically indistinguishable from the non-SOCE group on any measure of harm. For behavioral harm, risk ratios were 0.97-1.02. Harm was equivalent for the two groups despite the SOCE group having experienced higher lifetime and current minority stress, greater childhood adversity, and lower socioeconomic status. Logistic regression models that adjusted for these differences suggest that SOCE exposure reduced the effect of minority stress and childhood adversity for suicide attempts, although this effect did not fully account for the equivalence between the SOCE and non-SOCE groups.

CONCLUSION

Despite higher exposure to factors predicting behavioral harm-minority stress, childhood adversity, and lower socioeconomic background-sexual minority persons who had undergone failed SOCE therapy did not suffer higher psychological or social harm. Concerns to restrict or ban SOCE due to elevated harm are unfounded. Further study is needed to clarify the reasons for the absence of harm from SOCE.

Understanding Patterns of Healthy Aging Among Men Who Have Sex With Men: Protocol for an Observational Cohort Study

BACKGROUND

With the graying of sexual and gender minority communities and the growing number of people aged ≥50 years living with HIV, it is increasingly important to understand resilience in the context of the psychosocial aspects of aging and aging well.

OBJECTIVE

This paper aims to describe the methods and sample for the Understanding Patterns of Healthy Aging Among Men Who Have Sex With Men study.

METHODS

This observational cohort study was conducted within the Multisite AIDS Cohort Study (MACS) and was designed to explore resiliencies to explain patterns of health and illness among middle-aged and older sexual minority men. To be eligible, a participant had to be an active participant in the MACS, be at least 40 years of age as of April 1, 2016, and report any sex with another man since enrollment in the MACS.

RESULTS

Eligible participants (N=1318) completed six biannual surveys between April 2016 and April 2019. The mean age of the sample was 59.6 years (range 40-91 years). The sample was mostly White, educated, gay-identified, and included both HIV-positive (656/1318, 49.77%) and HIV-negative (662/1318, 50.23%) men.

CONCLUSIONS

Understanding resiliencies in aging is a critical springboard for the development of more holistic public health theories and interventions that support healthy aging among older sexual minority men.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/25750.

Sexual Orientation Change Efforts, Depressive Symptoms, and Suicidality Among Lesbian, Gay, and Bisexual Adults: A Cross-Sectional Study in South Korea

Purpose: We examined the association of sexual orientation change efforts (SOCE) with past-week depressive symptoms and past 12-month suicidal ideation and suicide attempts among Korean lesbian, gay, and bisexual adults. Methods: A cross-sectional study of 2168 participants was used. Lifetime SOCE was classified as "never experienced," "been advised but not undergone SOCE," and "undergone SOCE." Results: Participants who had undergone SOCE showed 1.44- and 2.35-times higher prevalence of suicidal ideation and suicide attempts than those without such practices. Significant associations were also observed between having advice on SOCE alone and all mental health indicators. Conclusion: Strict legal sanctions that prohibit SOCE are required in Korea.

Efficacy and risk of sexual orientation change efforts: a retrospective analysis of 125 exposed men

BACKGROUND

Voluntary therapeutic interventions to reduce unwanted same-sex sexuality are collectively known as sexual orientation change efforts (SOCE).  Currently almost all evidence addressing the contested question whether SOCE is effective or safe consists of anecdotes or very small sample qualitative studies of persons who currently identify as sexual minority and thus by definition failed to change.  We conducted this study to examine the efficacy and risk outcomes for a group of SOCE participants unbiased by current sexual orientation.       Methods: We examined a convenience sample of 125 men who had undergone SOCE for homosexual-to-heterosexual change in sexual attraction, identity and behavior, and for positive and negative changes in psychosocial problem domains (depression, suicidality, self-harm, self-esteem, social function, and alcohol or substance abuse).  Mean change was assessed by parametric (t-test) and nonparametric (Wilcoxon sign rank test) significance tests.   Results: Exposure to SOCE was associated with significant declines in same-sex attraction (from 5.7 to 4.1 on the Kinsey scale, p <.000), identification (4.8 to 3.6, p < .000), and sexual activity (2.4 to 1.5 on a 4-point scale of frequency, p < .000). From 45% to 69% of SOCE participants achieved at least partial remission of unwanted same-sex sexuality; full remission was achieved by 14% for sexual attraction and identification, and 26% for sexual behavior.  Rates were higher among married men, but 4-10% of participants experienced increased same-sex orientation after SOCE.  From 0.8% to 4.8% of participants reported marked or severe negative psychosocial change following SOCE, but 12.1% to 61.3% reported marked or severe positive psychosocial change.  Net change was significantly positive for all problem domains.   Conclusion: SOCE was perceived as an effective and safe therapeutic practice by this sample of participants.  We close by offering a unifying understanding of discrepant findings within this literature and caution against broad generalizations of our results.

Efficacy and risk of sexual orientation change efforts: a retrospective analysis of 125 exposed men

BACKGROUND

Voluntary therapeutic interventions to reduce unwanted same-sex sexuality are collectively known as sexual orientation change efforts (SOCE).  To date almost all evidence addressing the contested question whether SOCE is effective or safe has consisted of anecdotes or very small sample qualitative studies of persons who currently identify as sexual minority and thus by definition failed to change.  We conducted this study to examine the efficacy and risk outcomes for a group of SOCE participants unbiased by current sexual orientation.       Methods: We examined a convenience sample of 125 men who had undergone SOCE for homosexual-to-heterosexual change in sexual attraction, identity and behavior, and for positive and negative changes in psychosocial problem domains (depression, suicidality, self-harm, self-esteem, social function, and alcohol or substance abuse).  Mean change was assessed by parametric (t-test) and nonparametric (Wilcoxon sign rank test) significance tests.   Results: Exposure to SOCE was associated with significant declines in same-sex attraction (from 5.7 to 4.1 on the Kinsey scale, p <.000), identification (4.8 to 3.6, p < .000), and sexual activity (2.4 to 1.5 on a 4-point scale of frequency, p < .000).  Over 42.7% of SOCE participants achieved at least partial remission of unwanted same-sex sexuality; full remission was achieved by 14% for sexual attraction and identification, and 26% for sexual behavior.  Rates were higher among married men, but 4-10% of participants experienced increased same-sex orientation after SOCE.  From 0.8% to 4.8% of participants reported marked or severe negative psychosocial change following SOCE, but 12.1% to 61.3% reported marked or severe positive psychosocial change.  Net change was significantly positive for all problem domains.   Conclusion: SOCE was perceived as an effective and safe therapeutic practice by this sample of participants.  We close by offering a unifying understanding of discrepant findings within this literature and caution against broad generalizations of our results.