Gender Affirmation and the Nocebo Effect
By David Minor
One of the biggest myths of gender affirming care is that if parents don’t affirm their child as transgender, it will increase their risk of suicide. The oft-repeated phrase “Would you rather have a living son or a dead daughter?” ratchets up the stakes so that parents feel they have no other option but to affirm. In my work counselling gender questioning youth, they will often say that it is “unsafe” for them to communicate with family because their parents are non-affirming. This stems from the belief that non-affirmation is tantamount to psychological abuse. Not affirming a child’s stated gender identity doesn’t increase their risk of suicide, but it certainly leads to more conflict in the relationship. Constant arguing can increase stress and adversely impact the child’s mental health.
This points to an important question: is the problem with the parent not affirming or with the child’s belief that non-affirmation equals abuse? If you tell children that their parents’ failure to affirm could make them suicidal, you risk creating a self-fulfilling prophecy. Studies on the placebo effect have demonstrated the profound impact that belief has on our physical bodies. The placebo effect is a phenomenon where people’s mental and or physical health improves as a result of their belief that a certain intervention will help them. For example, if a group of people took a sugar pill that they believe is actually an antidepressant drug, many of them will improve as a result, despite the pill being inert. The placebo effect is powerful, and some argue it is as effective as antidepressant drugs in treating depression.
The opposite of the placebo effect is the nocebo effect, and unfortunately, it’s just as potent. The nocebo effect is a phenomenon where people’s mental and or physical health degrades as a result of their belief that a certain intervention will harm them. For example, one study showed that a belief that one had COVID-19 and increased worry about COVID-19 resulted in worse symptoms. In other words, people who were more scared of COVID got sicker from it.
Applying this concept to gender-questioning youth and their parents, it’s easy to see how believing the ‘non-affirmation increases-suicide-risk’ trope could worsen mental health symptoms in young people. A meta-analysis of studies on attachment and child mental health showed that insecure attachment with a parent led to increased risk for depression in youth. Part of a strong attachment is a belief that your parents love you, support you, and will be there for you no matter what.
A gender-affirming approach teaches young people that if their parents don’t affirm their new identity, then they don’t love and support them, or worse, are being abusive. I have seen how this has caused young people to become blind to anything good that their parents have done or are currently doing for them. They come to the conclusion that their parents are actively contributing to—or even the main cause of—their mental health problems. It puts the parents in the challenging position of trying to be supportive and loving by setting healthy boundaries around medical interventions when that very act of love is construed by their child as hateful.
By defining parental support as agreement with children’s wishes about their identities, the gender-affirmative paradigm allows no room for questioning or caution. Part of good parenting has always involved setting healthy boundaries, so when gender ‘experts’ say this isn’t the case, that should give us pause. This counterintuitive shift causes parents to second-guess themselves and lose confidence in their ability to guide and nurture their children. I’ve also observed that the inability to set boundaries around gender-related issues can seep into other areas such as sleep hygiene, negative peer influences, and screen time. Parents feel like they are walking on eggshells all the time.
The conflation of parental support and gender affirmation is further entrenched by well-meaning but misguided school counsellors, doctors, teachers, and psychologists who are following that model. They help solidify the parents’ non-affirming position as horrible and unloving. If all of society is saying one thing and the parent says another, it’s no wonder that impressionable children would think that their parents are the ones who are being unreasonable. Many of these professionals have been led to believe that criticism of gender-affirmative care is far-right or transphobic because mainstream media outlets are afraid of activist pushback if they run any stories that are even mildly gender critical. The parent and child consume contradictory information online which leads to disagreement, alienation, and family breakdown.
In this environment, the relationship between the child and non-affirming parent goes from one that is warm and connected to utter hostility in a very short window of time. To be sure, some of the dynamic is also developmentally normal—a part of the natural drive for independence that marks the transition from childhood to adolescence. However, when you teach children that their parents hate them unless they agree with them on gender identity, you are setting families up to fail. When the family is ineffective, parents can’t prepare their children to be properly socialized and mentally strong in a world where others will often disagree with them.
Gender-affirmative care reduces young people’s resilience in dealing with those who don’t see them as they would like to be seen. They may then hide from the world, fearing that someone might not affirm them. Whether this is by accident or malice doesn’t matter, for they have been told that intentions aren’t important, any “misgendering” (i.e., using pronouns corresponding to their sex) or “deadnaming” (i.e., using their given name) is potentially lethal to their psyche and must be avoided at all costs. Many of these young people are already introverted and have some social anxiety which is exacerbated by their fear of non-affirmation.
The vast majority of the people I work with who identify as transgender are already naturally sensitive. The ideology of gender-affirming care adds to the burden of this sensitivity by encouraging them to believe that other people have the power to determine their mental health by how they interact with them. This causes their loci of control (i.e., the location of ability to make change) to shift from inside them to factors external to them. One study found that an external locus of control was associated with higher levels of depression and anxiety. When someone believes they are at the mercy of outside events and don’t have the ability to make meaningful change in their lives, it leaves them feeling paralyzed.
We aren’t helping gender-questioning youth by tip-toeing around these issues. Instead we are contributing to a nocebo effect which tells them that anyone who disagrees about their beliefs on gender is a threat to their well-being. This adds to their fear and belief that they can’t cope in the outside world. Every interaction or casual glance becomes an opportunity for non-affirmation and the anticipated shift towards despair. We must stop telling parents and gender questioning children that any disagreement on gender identity is abusive and that non-affirmation is violence.
If young people could see that others who might disagree with them can still love and support them, it would make room for familial reconciliation and expand their capacity to engage with others who have different viewpoints. In a rapidly changing world, the ability to live and work with others who espouse different beliefs than our own is essential. We can help people develop this ability by disagreeing, while still being kind and sensitive to their needs.
David Minor is a CBT therapist, who lives in Vancouver, Canada and has worked extensively with gender dysphoria. He is a father of two boys, and enjoys reading, playing guitar and connecting with his neighbours. You can find him online at solidaritycoach.com.
Header photo by Lance Reis on Unsplash