Characteristics of health and well-being in former Jehovah’s Witnesses in Austria, Germany, and Switzerland

ABSTRACT Background: This study collected quantifiable data on the characteristics, health, and well-being of individuals who left or were expelled from a fundamentalist Christian faith community in Austria, Germany, or Switzerland. Methods: Data were collected using an online survey. Results: This study assessed a sample of former Jehovah’s Witnesses (N = 424, M age = 42.14, SD age = 12.57, 65% female). Most participants (66%) were born into this faith community. Half the sample left voluntarily, 21% were expelled, and 31% left due to having experienced abuse or maltreatment. One third reported suicidal thoughts; 10% had attempted suicide. The sample (especially women) reported relatively high levels of child maltreatment, moderate current health, clinically significant symptoms, high levels of stress, and low quality of life. Participants who left due to abuse or maltreatment reported more symptoms and child maltreatment. Discussion: Women and survivors of child maltreatment may represent particularly vulnerable sub-groups of former Jehovah’s Witnesses.


Introduction
Little quantifiable knowledge exists about individuals who disaffiliate from an exclusionary Christian faith community, such as Jehovah's Witnesses, the New Apostolic Church, or the Seventh-day Adventist Church (for a valuable exception see Ransom et al., 2021).Leaving or being expelled from such religious groups has the potential to be a highly stressful experience for the affected individuals (Ransom et al., 2022;Scheitle & Adamczyk, 2010).As such, ex-members may be considered a particularly vulnerable group for (the development of) poor physical and mental health and well-being (Buxant & Saroglou, 2008;Fenelon & Danielsen, 2016;Hookway & Habibis, 2015;Illig & Kaufmann, 2020;Namini & Murken, 2009).Gaining insight into the characteristics of such individuals, including quantifiable data on health and well-being, may allow for the identification of particularly vulnerable individuals, which is knowledge that is still broadly lacking.
The international project "Psychological strain and resilience after leaving or exclusion by a fundamentalist Christian faith community" was conducted with Germanspeaking (self-identified) ex-members, who left or were expelled from various fundamentalist Christian faith communities (see Thoma et al., 2022).This was a multicountry (i.e., Austria, Germany, Switzerland) triangular research project, incorporating qualitative (i.e., interviews) and quantitative (i.e., online survey) research.Within this project, the term fundamentalist Christian faith community was chosen to encompass the various exclusionary Christian faith communities that share common features.These shared features include the source of information (i.e., the Bible), the scriptural inerrancy, the basic belief content (e.g., narrative of salvation, prophecy of an apocalypse), the dichotomous thinking pattern (i.e., good versus evil), the comparatively smaller number of members compared to historically more established Christian faith communities, the distrust towards the secular society, as well as their exclusionary/ restrictive characteristic (Routledge et al., 2018).
Data from the quantitative study revealed that ex-members show diverse profiles with regard to well-being and resilience characteristics (Thoma et al., 2022).These profiles were identified on the basis of positive/negative deviations from the norm values (i.e., mean of the entire sample) on various indicators (i.e., perceived stress, negative and positive affect, symptoms of psychopathology, life satisfaction).Most participants showed a normative profile (i.e., values closest to the mean; 36%) or a resilient profile (i.e., lowest levels of stress, negative affect, and symptoms, as well as highest levels of life satisfaction and positive affect; 26%).A considerable number of individuals showed a vulnerable profile (i.e., overall negative values on all indictors; 27%) or an adverse profile (i.e., lowest levels of life satisfaction and positive affect, and highest levels of stress, negative affect, and symptoms; 11%).These findings showed that a substantial number of ex-members (i.e., 38%) displayed a potentially detrimental well-being pattern (Thoma et al., 2022).
Within the larger project on fundamentalist Christian faith communities, the largest sub-sample were self-identified ex-members of Jehovah's Witnesses (68%).It was therefore a central aim of the current study to gain more detailed information about the characteristics, health, and well-being of this homogeneous group of individuals, of which only little quantifiable knowledge exists (for an exception see Ransom et al., 2021).It was a further aim of this study to identify characteristics of particularly vulnerable individuals who may be at high risk for (the development of) poor physical and mental health and well-being.This knowledge is relevant for several reasons: Jehovah's Witnesses and comparable faith communities are often socially exclusive (Scheitle & Adamczyk, 2010), and have been known to practice (mandated) ostracism (Ransom et al., 2021).This may leave former members socially isolated after leaving or being expelled from the faith community, due to the loss of a familiar and supportive community in times of high psychosocial stress.Given the high importance of social bonds for human beings (e.g., Umberson & Montez, 2010), the experience of (mandated) ostracism may render ex-members at risk for poor physical and mental health and well-being.Fundamentalist faith communities, such as Jehovah's Witnesses, are also often negatively viewed and stigmatised by mainstream society (e.g., Buxant & Saroglou, 2008).As such, some ex-members may be reluctant to seek help due to self-stigmatisation or the expectation that health professionals would not understand the particularities of their situation.The negative effect of self-stigmatisation on help-seeking, especially among minority groups, has been demonstrated in previous research with immigrant samples (Giacco et al., 2014;Pattyn et al., 2014).Hence, a better understanding of this particular minority group in the general population and among health professionals may increase their social integration and lower the threshold for help-seeking for those in need.
It is also of crucial importance to consider early-life adversities in order to understand interindividual health differences in general (e.g., Thoma, Bernays, Eising, Maercker, et al., 2021;Thoma, Bernays, Eising, Pfluger, et al., 2021), as well as in response to stress (e.g., McLaughlin, Conron, et al., 2010).Various religious denominations, groups, and communities, including the Jehovah's Witnesses (see Rashid & Barron, 2022), have been confronted with the topic of child maltreatment (e.g., Barker & Galliher, 2017;Bottoms et al., 2015;Lusky-Weisrose et al., 2021;Terry, 2015).Therefore, this study also aimed to describe the level of exposure to child maltreatment in this sample of self-identified former Jehovah's Witnesses.Lastly, the type of exit (e.g., forced or voluntary) may be relevant for the identification of highly vulnerable ex-members (Ransom et al., 2021).Thus, this study additionally aimed to explore whether different types and reasons for exit (i.e., expelled, experienced trauma, personal reasons) may be linked to different health and well-being outcomes.

Study design
The study was conducted at the main study site of the University of Zurich, Switzerland, in collaboration with the University of Vienna, Austria.The study protocol was approved by the Ethics Committees of the University of Vienna, Austria (ID: 00662); the German Psychological Society [Deutsche Gesellschaft für Psychologie, DGPs], Germany (ID: 2021-01-08VA); and the Faculty of Arts and Social Sciences in the University of Zurich, Switzerland (ID: 20.12.18).Informed consent was provided by all participants.Participants could withdraw from the study at any given time throughout the survey.No financial compensation was offered to participants.The data of this study were collected and stored anonymously.

Participants and recruitment
Inclusion criteria were former membership in a fundamentalist Christian faith community, minimum age of 18 years, native German speaker / fluent in German, and residency in Austria, Germany, or Switzerland.In the current study, only data from ex-members of Jehovah's Witnesses were included in the analyses, as they represented the largest sub-sample (68%) of participants in the online survey.Recruitment took place between February and June 2021 using multiple recruitment avenues.Organisations, communities, individual contacts, publicly active ex-members, and various support groups for ex-members and their relatives were contacted and provided with the study information.
They were asked to spread the word about the study if they indicated agreement with the study's purpose and the willingness to support the recruitment efforts.In addition, study information was distributed online using social media channels (e.g., Facebook, YouTube) and participants were also recruited via snowball sampling.The first author (MVT), as well as two research assistants, provided further information about the aim and content of the study if requested by potential participants or distributors of the study information.Recruitment efforts were conducted internationally (i.e., in German speaking countries), via multiple channels in order to gain a broader diversity and larger number of ex-members.

Procedure
For a detailed description of the study procedure see Thoma et al. (2022), which is summarised briefly here.The survey was programmed using the online research software Unipark (Unipark & QuestBack, 2016).Potentially interested persons could access the study through a link that allowed for anonymous participation.Before accessing the questionnaires, the inclusion criteria were screened for, complete study information was given, and informed consent had to be provided by participants.The questionnaires (see Measures section below) were presented in a randomised order.Throughout the survey, participants were repeatedly informed about the opportunity to download a list of support options.

Socio-demographic information
The following socio-demographic information was assessed: Age, sex, relationship status, highest level of education, employment status, and satisfaction with financial status.
Information related to membership, exit, and current situation An extensive battery of questions (see Supplementary Material) was developed to specifically assess data on membership (e.g., mode of joining, extent of involvement), exit (e.g., year and mode of exit, reason for leaving the faith community), and the current situation of the former members (i.e., general life situation, change in beliefs).

Stress and trauma
To assess current perceived stress, the German version of the Perceived Stress Scale (PSS-10; Cohen et al., 1983;Klein et al., 2016) was applied.The PSS-10 measures the perceived stress in the last month, with 10 items rated on a five-point scale from "0 = never" to "4 = always" (potential range = 0 to 40).In the present study, reliability was α = .90for the PSS.In addition, the Stress Numerical Rating Scale-11 (Stress NRS-11;Karvounides et al., 2016) was used to assess momentary stress by applying a single item rated on a scale from "0 = no stress" to "10 = maximum stress".
To assess trauma experienced as a minor, the German version of the Childhood Trauma Questionnaire (CTQ; Gast et al., 2001;Klinitzke et al., 2012) was applied.The CTQ measures maltreatment in childhood and adolescence, with 25 items (and three validity items) rated on a five-point scale from "1 = never true" to "5 = very often true".The items belong to five subscales (i.e., emotional, and physical neglect; emotional, physical, and sexual abuse), with a potential range for each subscale from 5 to 25. Reliability was α = .89for emotional neglect, α = .59for physical neglect, α = .87for emotional abuse, α = .87for physical abuse, α = .96for sexual abuse, and α = .93for the CTQ total score.

Well-being
To assess general well-being during the last two weeks, the German version of the World Health Organization-5 index (WHO-5; Brähler et al., 2007) was applied.The WHO-5 consists of five items rated on a six-point scale from "0 = all the time" to "5 = at no time" (potential range = 5 to 25).Reliability was α = .89in the current study.

Physical and mental health
To assess current subjectively perceived general health, a single item from the German version of the Short Form Health Survey (SF-36; Bullinger 1995) was applied.The item "How would you describe your health status in general?" is rated on a five-point scale from "1 = excellent" to "5 = bad".To assess current subjectively perceived mental health, the German version of the Brief Symptom Inventory (BSI; Derogatis & Melisaratos, 1983;Franke, 2000) was applied.The BSI assesses a variety of psychological and psychosomatic symptoms and consists of 53 items rated on a 5-point scale from "0 = not at all" to "4 = extremely" (potential range = 0 to 212).Standardised T-scores of the global index (Global Severity Index, GSI) were used in the current study, with a T-score of 63 or greater indicating clinically significant symptoms and distress (Franke, 2000).Reliability was α = .97for the BSI GSI.
In addition, further health-related questions were administered to assess various concurrent mental and physical health aspects.This included information about the diagnosis of any mental health disorder, whether the participant is in psychotherapeutic treatment, whether they take medication for mental or physical health complaints, as well as the presence of (and extent of functional impairment by) a chronic physical illness.

Data analysis
Statistical analyses were performed using SPSS version 26.0.0.0 and figures were created using R version 4.1.3.Gender differences were computed using t-tests for metric outcomes.For more detailed analyses, participants were categorised according to their mode of exit / reason(s) for leaving the faith community, resulting in three different groups (i.e., expelled, experienced trauma, personal reasons).This categorisation was based on two items from the self-developed questionnaire (see items 29 and 30 in the Supplementary Material).Item 29 asked how the contact with the faith community ended.Participants who indicated that they were expelled from the faith community (e.g., because of improper behaviour/violations of the community rules) were categorised into the group "expelled".If participants were not expelled but answered that they either officially left the faith community on their own accord or stopped attending (the activities) but did not officially leave the community, then they were forwarded to a subsequent question (item 30) about reason(s) for ending contact with the faith community (multiple answers were possible).Participants who indicated that the experience of abuse or maltreatment (i.e., physical, psychological, sexual) or observing the abuse or maltreatment of others was a/the reason for ending the contact with the faith community, were categorised into the group "experienced trauma", irrespective of any other indicated reasons.All other participants were categorised into the group "personal reasons" (e.g., doubts about the teachings or way of life, too many restrictions in different areas of life, conflict with other members).Group differences regarding the mode of exit / reason(s) for leaving the faith community were analysed using one-way ANOVAs.All statistical tests were considered significant if the p-value was less than .05.

Results
In the following sections, the basic socio-demographic characteristics of the sample will first be presented, followed by a description of the results regarding membership, exit, and the current situation.The last results section will present various aspects of membership and exit and the associations with current health, perceived stress, and quality of life.

Sample characteristics
In total, N = 424 former Jehovah's Witnesses (M age = 42.14, SD age = 12.57, 65% female) participated in the study (see Table 1 for sample characteristics).The majority of the sample (87%) currently reside in Germany, 8% in Switzerland, and 5% in Austria.Twenty-six percent of the sample were in a committed relationship, 39% were married, and 2% were in a registered partnership.Furthermore, 12% had completed upper secondary school education, 20% had a university degree, and 72% were currently employed.One-third of the sample indicated that they were "very unsatisfied" or "unsatisfied" with their current financial situation, with the remainder being "satisfied" (59%) or "very satisfied" (12%).

Data on membership
Reason for joining the faith community Regarding the reason for joining the faith community (multiple answers were possible), most participants (66%) indicated that they were born into the Jehovah's Witnesses.Those who were not born into this faith community, indicated that they joined during childhood (age 1-13 years; 17%), during adolescence (14-18 years; 6%), or in adulthood (19 years or older; 11%).Those who were not born into the Jehovah's Witnesses indicated that they joined because of their parents (29%) or other close persons during childhood/ adolescence (7%).Further reasons for joining included: Because the beliefs attracted them (10%), because the faith community seemed to be the solution to their problems and the answer to their questions (9%), because their lifestyle convinced them (5%), because this enable them to maintain contact with important or close persons, such as family members or friends (5%), because they were looking for a place of community and belonging (4%), and because they found comfort in the faith community after a twist of fate (2%).

Social life during membership
Participants indicated that during their time in the faith community, their social life was relatively restricted to other members of the Jehovah's Witnesses: 62% indicated that all or many of their family members were also members of the faith community and 71% reported that all or many of their closest friends were members.Furthermore, 75% stated that during their time in the faith community, they gave up, avoided, or reduced contact with people who were not part of the faith community.The most common reasons stated for this were either completely (47%) or somewhat (42%) due to the prevailing norms of the faith community, with the remainder indicating that it was either somewhat (9%) or completely (3%) due to their own personal beliefs.
Commitment, community activities, and financial aspects during membership More than half the participants (62%) felt (very) strongly connected to the faith community during their membership time.On average, participants spent 15.77 h (SD = 14.71) per week involved with the community and its aims, such as gatherings, missionary work, or the study of literature.For 70% of the sample, there was always or often not enough time and energy for work, family, friendships, and hobbies, in addition to their responsibilities in the faith community.Regarding financial aspects, 56% of participants indicated that they invested money into the faith community and its purposes, with 8% indicating that they experienced great or slight financial difficulties because they invested some of their income or property in the faith community.

Data on exit
Mode of and reason for exit from the faith community At the time of the survey, the mean time since the exit from the faith community was 12.59 years (SD = 10.61,range: 0-63 years).On average, participants left the faith community after M = 29.56 years (SD = 12.24, range: 6-71 years).Regarding the mode of exit, 47% of participants left the faith community on their own accord, 30% stopped attending (the activities) but did not officially leave the faith community, 21% were expelled from the faith community (e.g., because of improper behaviour/violations of the community rules), and 2% indicated various other reasons.Reasons given for leaving the faith community or stopping attendance at activities were the following (multiple answers were possible): Doubts about the teachings or way of life (83%), too many restrictions in different areas of life (57%), differing ideas about ethics and moral values (56%), they experienced (31%) or observed (23%) abuse or maltreatment (physical, psychological, sexual), they had conflicts with other members (19%), they changed the focus of their life (15%), or they found a different faith community (1%).For 16% of participants, the exit from the faith community resulted in a breakup/divorce of their relationship/ marriage.
Coping with and experiences related to the exit After the exit, 65% and 47% of the sample reported that their mental and physical health, respectively, improved a lot or a little.While 6% of participants indicated that their mental health stayed the same, 29% reported that it deteriorated after the exit.With respect to physical health, 34% of participants reported that it stayed the same and 20% reported that it deteriorated after the exit.
Regarding coping after the exit, after the contact with the faith community ended, 31% of participants reported that they depended on professional support and 38% reported that they got into a crisis and did not know what they should do with their life anymore (multiple answers possible, see Table 2 for an overview).Furthermore, 33% reported that they had thoughts about taking their own life and 10% attempted to take their own life following the exit.However, 37% reported that they enjoyed their lives to the fullest and did things that they were not allowed to do before, and 58% formed new friends/contacts and reactivated previous contacts.
Regarding aggravating circumstances after ending contact with the faith community (see Table 3 for an overview), most participants (77%) experienced shunning/exclusion by active members of the faith community and 71% stated that they had to give up relationships within the faith community.Furthermore, 36% indicated a fear of punishment from God, whereas 7% reported no aggravating circumstances/activities.

General aspects and beliefs
Participants indicated that the faith community affects their (everyday) life strongly (15%) or very strongly (11%).For most participants, their belief in God decreased strongly (59%) or moderately (13%) after ending contact with the faith community.
Current physical and mental health, perceived stress, and quality of life Regarding current general perceived health (indexed by the single item of the SF-36), the average was 3.08 (SD = .96),indicating a moderate level of current general health.Furthermore, 43% indicated that they had a current chronic physical disease, of which 36% felt moderately, 10% strongly, and 10% very strongly limited by them in their daily lives.Additionally, 36% take medication regularly because of their physical health complaints.
Regarding mental health (indexed by the global index of the BSI), the overall mean score was 50.99 (SD = 38.32),which translates into a T-score of 72, indicating clinically significant symptoms and distress.Overall, 63% of the whole sample was within the clinical range (i.e., T > 62, as per the manual) in the BSI global index.Female participants reported significantly higher scores than males in the global index of the BSI (56.92 vs. 39.03,t (379.36)= 1.15, p < .001).In percentages, this translates to 69% of all female participants and 51% of all male participants being in the clinical range of the BSI global index.From the total sample, 41% indicated that they had a diagnosed mental health disorder, 28%   were in psychotherapeutic treatment at the time of the survey, and 20% take medication regularly because of their mental health complaints.
Regarding current perceived stress (indexed by the PSS-10), participants reported a mean of 19.39 (SD = 7.89), indicating a relatively high level of stress.Females reported a higher stress level in comparison to males (20.51 vs. 17.25, t(420) = 4.13, p < .001).The relatively high perceived stress level of the sample was also reflected in the single-item stress measure (indexed by the Stress NRS-11), with a mean score of 5.36 (SD = 2.70).
With respect to current quality of life (indexed by the WHO-5), the mean score for the total sample was 11.26 (SD = 6.00), which is relatively low.Females reported significantly lower levels of quality of life in comparison to males (10.80 vs. 12.22, t(420) = 2.33, p = .020).
Associations between membership aspects, exit and current health, perceived stress, and quality of life Membership and current health, perceived stress, and quality of life The duration of the membership was not associated with current mental health (r(422) = -.087,p = .072),or quality of life (r(422) = .068,p = .160).However, it showed a small, but significant negative association with current perceived stress (r(422) = −.142,p = .003),indicating that (exit after) a longer membership was linked to lower current perceived stress.Furthermore, the number of years since the exit was negatively correlated with current mental health (r(422) = −.105,p = .031),indicating that the more time that had passed since the exit, the better the current mental health.Significant associations were not found for the number of years since exit and current perceived stress (r(422) = −.079,p = .105),nor for quality of life (r(422) = .064,p = .189).

Exit and current mental health, perceived stress, and quality of life
The mode of and reason for exit (i.e., expelled, experienced trauma, personal reasons) was significantly associated with various (mental) health-related aspects.For instance, participants who left the faith community for personal reasons reported lower current perceived stress (M = 18.15 vs. M = 21.31,F(2, 421) = 6.594, p = .002),and a higher quality of life (M = 12.15 vs M = 10.29,F(2, 421) = 4.420, p = .013),compared to participants who left because of experienced personal trauma.Participants who left the faith community due to experienced trauma, reported significantly more psychological and psychosomatic symptoms (M = 59.95,F(2, 421) = 15.649,p < .001),as well as more personal maltreatment in childhood and adolescence (M = 67.17,F(2, 421) = 26.601,p < .001),compared to participants who left due to personal reasons (in this group: psychological/psychosomatic symptoms: M = 37.98, trauma: M = 54.83) or those who were expelled (in this group: psychological/ psychosomatic symptoms: M = 46.93,trauma: M = 58.90).The group comparisons are depicted in Figure 1.

Discussion
The current study aimed to obtain quantifiable data on characteristics, health, and wellbeing in self-identified former Jehovah's Witnesses living in Austria, Germany, or Switzerland; and to identify characteristics of particularly vulnerable individuals.

Sample characteristics contrasted with normative data, statistics, or representative samples from Germany
Given that most participants were German residents (87%), the current findings will be contrasted in the discussion with normative data, statistics, or representative samples from Germany.The sample of former Jehovah's Witnesses in this study were, on average, middle-aged, with a rather large age range of 19 to 83 years.While women (65%) were overrepresented in the current study, this parallels the female percentage (62%) in the quantitative study by Ransom et al. (2021) with former Jehovah's Witnesses in the United Kingdom.Nevertheless, this may reflect a gender bias in the participation of online surveys (Smith, 2008), rather than the gender distribution of former Jehovah's Witnesses.In comparison to the general German population (numbers provided by the Social Report for the Federal Republic of Germany, 2021), the participants in this study were more likely to be single, separated, divorced, or widowed (i.e., 23% versus 33% in the current study).There was a comparable proportion of individuals with higher professional or university as the highest level of education (i.e., 25.2% versus 28% in the current study); and comparable unemployment rates (i.e., 5.6% versus 6% in the current study).As such, with the exception of gender and relationship status, the socio-demographic characteristics of the current sample were comparable to the general German population.

Child maltreatment reported by self-Identified former Jehovah's Witnesses
Regarding child maltreatment, in contrast to data from a representative sample of the German population (Iffland et al., 2013), the current sample reported markedly higher levels of emotional neglect (i.e., 13.9% versus 81% in the current study), emotional abuse (i.e., 10.2% versus 65% in the current study), physical abuse (i.e., 12% versus 34% in the current study), and sexual abuse (i.e., 6.2% versus 18% in the current study).In contrast, the reports of physical neglect in the current study were considerably lower (i.e., 48.4% versus 33% in the current study).While gender differences were only shown in the representative German sample for sexual abuse (i.e., higher levels for women; see Iffland et al., 2013), significant gender differences were detected across all child abuse types in the current sample.It is very important to highlight that the comparatively high level of child maltreatment in the current sample may be unrelated to the Jehovah's Witnesses membership.For instance, it could be that those who were not born into the faith community may have been affected by child maltreatment before becoming a member.Nevertheless, some inferences may be made for the current sample as most participants (89%) joined the faith community before adulthood (i.e., 66% were born into it) and reported that their social life was relatively restricted to other members.Additionally, a substantial number of participants reported that their reason for leaving the faith community was that they experienced (31%) or observed (23%) abuse or maltreatment.It is therefore possible that being a member of Jehovah's Witnesses was linked to a higher risk in the current sample for exposure to child maltreatment.Child maltreatment is a topic that the Jehovah's Witnesses faith community has been confronted with in the past (Rashid & Barron, 2022), similar to other religious denominations, groups, and communities (e.g., Barker & Galliher, 2017;Bottoms et al., 2015;Lusky-Weisrose et al., 2021;Terry, 2015).Thus, regardless of whether the child maltreatment was experienced before, during, or independent of the membership, the high level of child maltreatment reported by ex-members is an important topic to be addressed by the faith community, as well as by research.

Coping with the exit
Participants within the current sample differed quite substantially with respect to how they coped with the exit.This vast heterogeneity in the outcomes corroborates previous research suggesting that individuals differ substantially with respect to how they cope with stressful life situations (Rutter, 2006), and with respect to the exit from a fundamentalist Christian faith community (Thoma et al., 2022).
Half the sample reported positive outcomes after the exit.Several negative outcomes were also reported, which have important implications when compared to representative German populations.For instance, the average current stress level in the present sample, and particularly that of female participants, was relatively high compared to representative German samples.For instance, a study by Klein et al. (2016) showed comparatively lower perceived stress in a representative German community sample of N = 2463 individuals aged between 14 and 90 years (12.57versus 19.39 for the total sample in the current study).Furthermore, participants in the current study reported a comparatively high level of chronic diseases in contrast to data from a representative German sample (i.e., 43% versus 26.5% in Mielck et al., 2014).Quality of life in the current sample was also relatively low in comparison to a representative German study (i.e., 11.26 versus 17.58 in Brähler et al., 2007).Moreover, the total sample (with significant gender differences) reported clinically significant symptoms and distress (Franke, 2000), with over 40% also reporting a diagnosed mental health disorder.This is considerably higher than the 12-month prevalence of mental health disorders in a representative German cohort (i.e., 27.7% in Jacobi et al., 2014).The comparatively high stress indices and the moderate to poor health and well-being data indicate that a substantial number of the (particularly female) self-identified former Jehovah's Witnesses in the current sample may benefit from increased medical and psychotherapeutic support.How high or low this number may be can currently only be speculated.In the current study, 30% of the self-identified ex-members of Jehovah's Witnesses indicated that they depended on professional support after the exit.However, with the applied purposive sampling method it is not possible to deduce whether this could reflect an over-or underestimation of the actual number.Nevertheless, the 30% identified in this study may represent the best currently available estimate, pending results from future representative studies with this population.It is also unclear to what extent the individuals who sought professional support may have encountered stigmatisation or misunderstanding in the help-seeking process.As such, future studies are needed to shed light on the help-seeking process, as well as the appropriateness and quality of professional support received.

Interpreting health and well-being outcomes
This comparatively poor level of health and well-being in the total sample may be related to the negative and stressful social consequences reported by most participants after the exit.This included experiences of shunning or exclusion by active members and the loss of relationships.For around one-sixth of the sample, leaving the faith community resulted in the ending of a core relationship, such as a divorce.This represents a major life stressor that has been linked to poor health outcomes (e.g., Dupre et al., 2015).The practice of ostracism has well-known negative effects upon affected individuals (see for instance Bastian & Haslam, 2010).Given that social support is a key resource in dealing with critical life events (Maercker et al., 2017), losing (core) relationships in response to the exit may be regarded as a loss of crucial resources.Furthermore, a small, though non-negligible number of participants (i.e., 14%) reported having a fear of threat from the faith community, which can an additional stressor after the exit.In addition, more than twothirds of the sample reported that their belief in God strongly or moderately decreased following the exit, which can be regarded as a loss of a meaningful resource in dealing with potentially stressful situations (see for instance Pargament, 2002).Overall, the "exit costs" (Scheitle & Adamczyk, 2010, p. 325) for this sample of self-identified former Jehovah's Witnesses not only include psychosocial stressors, such as the experience of shunning or various fears, but also the loss of relevant protective or resilience resources, such as (core) relationships.
Characteristics related to a higher risk for poor health and well-Being in ex-Members Regarding risk constellations, the current results indicate that the mode of and reason for exit (i.e., expelled, experienced trauma, personal reasons) may be more relevant for understanding the individual health and well-being differences of ex-members than the duration of membership or the number of years since the exit.Individuals who left because of experienced trauma reported more psychological and psychosomatic symptoms compared to the other two groups; as well as more perceived stress and a lower quality of life compared to those who left for personal reasons.It may be that the individuals who reported leaving because of experienced trauma were those who experienced the most child maltreatment or who were most affected by it, compared to those who were expelled or left for personal reasons (who may also have been affected by child maltreatment, but did not mention it as the reason for exit).It is well-established that survivors of child maltreatment have a higher risk for the development of mental health disorders (e.g., Humphreys et al., 2020;McLaughlin, Green, et al., 2010;Thoma, Bernays, Eising, Maercker, et al., 2021), and physical illnesses (e.g., Hughes et al., 2017;Thoma, Bernays, Eising, Pfluger, et al., 2021).However, it is crucial to acknowledge that other factors that were not assessed in this study could also help explain the differences in health and well-being.For example, individual variation may be linked to an acute (e.g., due to the COVID-19 pandemic) or chronic (e.g., low income) vulnerable socio-economic situation, or due to particularities in their personality traits or psychosocial characteristics, which may even have initially led them to join the faith group.

Limitations
With regard to study limitations, the following should be considered: (1) The cross-sectional and retrospective study design (a) hinders a causal interpretation of the results; (b) does not allow for any statements to be made about intraindividual developments; and (c) bears the risk of various biases, such as self-presentation or recall bias, particularly with regard to more distant experiences, such as child maltreatment (Church et al., 2017).Furthermore, given the lack of repeated (i.e., pre-, peri-, and post-) measurements, the comparatively poorer physical and mental health and well-being of the sample cannot be conclusively attributed to the membership or the exit.Additionally, given that the study was conducted during a global pandemic, it may be that the comparatively poorer health and well-being could be (partly) attributed to various aspects of .(2) It must be emphasised that the recruitment method, i.e., non-probability, purposive sampling, (a) may have led to a self-selection bias; (b) does not guarantee that the participants were ex-members of a particular fundamentalist Christian faith community; and (c) restricts generalisation due to the unknown representativeness of the sample.(3) The study design of an online programmed survey may have excluded individuals who were not familiar with web-based questionnaires, or who may not have trusted the anonymous data assessment.(4) A further limitation is the lack of control groups, such as active members of Jehovah's Witnesses, or individuals who were never members of any faith community.There is a lack of information regarding the general health and well-being of Jehovah's Witnesses who have not left and thus the results of the current study can only be contrasted with normative data or data from representative studies.As such, it is not known whether the comparatively poorer health and well-being of the current sample is merely reflecting the general level of health and well-being of members of Jehovah's Witnesses in German speaking countries.(5) The approach of categorising participants into three groups (i.e., expelled, experienced trauma, personal reasons) was based on the chosen answer(s) of two different items, of which the answer options of one item (i.e., item 30) were not exclusive.As such, it is possible that participants could have experienced trauma but left mainly due to personal reasons, or that participants who were expelled also observed abuse or maltreatment.( 6) The applied measure of child maltreatment was not adapted to the particular context within which the maltreatment was experienced (e.g., within the faith community, school, or family of origin).As such, no statements can be made about the context of where the reported child maltreatment was experienced (i.e., before, during, or independent of the membership).

Future outlook
This is one of the largest studies conducted with former members of Jehovah's Witnesses in general, and the largest study ever conducted with German speaking ex-members of Jehovah's Witnesses.While this empirical contribution adds substantial new quantifiable knowledge on the health and well-being of a subset (i.e., self-selected, self-identified, interested in research participation) of former Jehovah's Witnesses, it also raises further questions on this topic.The presented results are by no means conclusive and may be regarded as preliminary, with a need for further empirical work in this evolving research field.For example, the use of qualitative interview studies could not only provide profound insights into the lived experiences, but also other relevant aspects of the lives of ex-members (e.g., external social context, culture, intergenerational transmission of beliefs), before, during, and after the exit.This could be followed up by a large-scale, prospective longitudinal study, with several measurement points and a mixed-methods design.Such a study should assess a broad set of factors, including socio-economic situation, personality traits, as well as cognitive, emotional, and behavioural coping strategies.Importantly, future empirical studies should include control groups with individuals who have never been members of a fundamentalist faith community, as well as active members of Jehovah's Witnesses.Including control groups would help researchers to make more specific assumptions and conclusions about the reasons for interindividual variation in coping with the exit.

Conclusion
The data indicate considerable variation in health and well-being among the current sample of self-identified ex-members of Jehovah's Witnesses.Results show a substantially higher risk for most types of child maltreatment (with the exception of physical neglect), high levels of psychosocial stress linked to the exit (i.e., shunning, fears of making the wrong decision, punishment from God, or threat from the faith community), and the loss of crucial protective and resilience resources in response to the exit (i.e., loss of relationships, diminished belief in God).The findings suggest that the mode of and reason for exit, in addition to child maltreatment, are relevant risk factors for poor health and well-being in the current sample of self-identified exmembers.These individuals may be in need of or particularly benefit from (specialised) medical and psychotherapeutic attention or other tailored support.However, given the current lack of knowledge regarding the particular needs of these help-seeking individuals and the lack of validated treatment approaches for this particular group of individuals, there is not (yet) a satisfactory answer regarding the specific nature of this treatment and tailored support.It is recommended that further research and practice efforts in this field are dedicated to addressing this issue.Nonetheless, it is suggested that ex-members seek the help of professionals that possess a certain amount of knowledge regarding common practices of fundamentalist Christian faith communities.Professionals may take directives for the treatment of help-seeking ex-members from relevant treatment manuals directed towards survivors of child maltreatment, complex trauma, and/or social exclusion.

Disclosure statement
No potential conflict of interest was reported by the author(s).
by active members of the faith community 77 Relationships within the community that I had to give up 71 Fear of making a wrong decision because the teachings or way of life might have been the right thing after all 40 Fear of punishment from God 36 Loss of a framework of daily and weekly structure 20 Fear of threat from the community 14 There were no aggravating circumstances/activities 7 Note: N = 424.Multiple answers were possible.Item 35 = "Did you experience one or more of the following aggravating circumstances after ending contact with the faith community?".

Figure 1 .
Figure 1.(a-d) Reason for exit and (a) current psychological and psychosomatic symptoms, (b) childhood maltreatment, (c) current perceived stress, and (d) current quality of life.Note: Depicted here are the individual data points, the standard error of the mean, and the violin plots that show the probability distribution.BSI-GSI = Brief Symptom Inventory -Global Severity Index, CTQ = Childhood Trauma Questionnaire, PSS-10 = Perceived Stress Scale, WHO-5 = World Health Organization-5 index.*** = p < .001,** = p < .01,* = p < .05,NS = Not significant.

Table 2 .
Participants' coping after ending contact with the faith community (item 34).= 424.Multiple answers were possible.Item 34 = "How did you fare after you ended your contact with the faith community?".

Table 3 .
Participants' experiences after ending contact with the faith community (item 35).