“We shouldn’t have had you”: Lived experiences and socioecological mechanisms sustaining gender identity conversion practices in China

Background Gender identity conversion practices (GICPs), interventions intended to suppress or change an individual’s gender identity or expression, persist globally despite professional consensus that they are harmful. Evidence from non-Western, collectivistic contexts remains limited, particularly regarding the socioecological mechanisms sustaining GICPs and their harms to transgender and nonbinary (TGNB) individuals. This study examined how GICPs are enacted and maintained within China’s family-centered socioecology, to inform cultural-responsive gender-affirming care and public health policy.Methods Between June 2023 and March 2024, we conducted in-depth, semi-structured interviews with nine TGNB young adults who had experienced GICPs in China. Participants were purposively sampled to capture variation in age at exposure and conversion contexts. Data was analyzed using reflexive thematic analysis.Results Five forms of GICPs emerged: psychiatric, psychological, religious, military-style correctional school–based, and family-driven practices. Across contexts, participants described severe biopsychosocial harms, including suicidal ideation, family estrangement, and mistrust of mental-health services. Furthermore, we developed a conceptual framework identifying socioecological mechanisms sustaining GICPs across micro-, meso-, and macro-level systems. Families initiated GICPs and collaborated with professionals to enforce them, while sociocultural norms and the absence of legal and professional protections reinforced these harmful practices.Interpretation GICPs targeting TGNB young adults in China constitute a preventable public health harm that contributes to health inequities. Findings underscore the need for explicit policy prohibitions, strengthened regulatory oversight, mandatory gender-affirming training for health professionals, and expanded access to culturally responsive clinical care and support services.