Let’s talk

There’s broad agreement that psychotherapy must come first for gender-distressed youth, but diverging views over whether medical transition should be among the possible destinations

New on stage

Next month in Manhattan, the organisation Therapy First will hold its inaugural conference. The name Therapy First encapsulates its purpose: to put psychotherapy before any medical treatment of young people who are gender-distressed. The conference theme poses a question—Identities in the Therapy Room: What is Unfolding?

“Therapy First sees the problems in youth gender care as part of a larger challenge facing the psychotherapy profession and young people,” says the group’s president Paul Garcia-Ryan, a therapist who is a licensed clinical social worker.

“These young people are developing in an environment that is unlike the environment that previous generations have developed in.”

For these reasons, “the conference is starting with questions as opposed to answers”.

Therapy First began in 2021 as the Gender Exploratory Therapy Association (GETA) but now disavows that therapeutic term. Fairly or not, gender exploratory therapy has been framed as unethical “conversion therapy” by advocates of the gender-affirming treatment model. In 2023, with Garcia-Ryan coming in as president, the organisation was rebranded to clarify its worldview, although that remains uncertain for some observers.

In any event, Therapy First has grown to 400-plus members from 21 countries. It also has a large network of clinicians associated with the organisation outside of membership, Garcia-Ryan says. He says inquiries from families looking for help are on the increase, reaching or exceeding 100 a month. Therapy First’s activities include training, webinars and membership retreats.

The New York City conference, over the weekend of October 17-18, is open to mental health practitioners only, and any recording or social media posts about the proceedings are “strictly prohibited”.

“We’re wanting to create the conditions for clinicians to speak openly with one another, in the moment, during that weekend,” Garcia-Ryan says.

He notes that two trans clinicians—psychologist Dr Erica Anderson and psychotherapist Joe Berger—will present at the conference.

“Therapy First has always supported transgender individuals, and this support is rooted in deeply held principles. We’ve always welcomed transgender clinicians, and several have played significant roles in the organisation.”

Garcia-Ryan envisions a dialogue at the conference grappling with fundamental questions at a time of adolescent identity formation in the shadow of “digital life algorithms”.

“What is it that therapists are actually supposed to do? What is their role?” he asks. “Are clinicians being trained properly to be professionally and culturally competent in working with these young people?

“We see the challenges our profession now faces in caring for gender-distressed youth as having emerged amid breakdowns in the mental health system in such a way that therapists aren’t really being trained properly, and there are many therapists who actually aren’t practising therapy.”

Broad church

The conference includes presenters as various as Sasha Ayad, a leading counsellor who thought it was mind-blowing when, early on, she heard of parents seeking out affirmation and medicalisation for daughters apparently under peer influence; Lisa Marchiano, a Jungian analyst who almost a decade ago pointed out what appeared to be a “psychic epidemic” among teenage girls adopting trans identities; Dr Laura Edwards-Leeper, founding psychologist at the first specialist paediatric gender clinic in the US; and Dr Anderson, a trans woman who has assessed young people for medical transition.

It’s worth adding that the latter two practitioners of the gender-affirming treatment model have spoken out, at some cost, against poor assessment and hasty medicalised transition of youth. And Dr Anderson discerns some group influence in the rapid uptake of trans identity among the screen-absorbed young, especially during the period of Covid-enforced home learning.

And, of course, therapists critical of gender-affirming care often pay a professional price, along with being smeared as bigoted transphobes.

Dr Anderson’s conference talk is on point. Its title: The Importance of Finding Common Ground. The panel discussion will include clinical psychologist Dr Anna Hutchinson, a whistleblower from the now-shuttered, London-based Tavistock gender clinic, which was the world’s largest of its kind. So, the conference, like the organisation, is presented as a broad church.

“We very intentionally chose clinicians from different perspectives as a way to start to open up some dialogue,” Garcia-Ryan says. “Every serious profession gets together to talk shop, and this just hasn’t really happened in the mental health field when it comes to youth gender distress and the care that the mental health profession is offering these young people.

“Controversies surrounding medicalized treatment have left many unsure of how to move forward. Families are seeking care they can trust, and professionals are seeking training they can rely on. Therapy First was formed to help address that need,” Garcia-Ryan says in the group’s 2025 annual report.

In a field beset by polarised views, he says “the only agenda we are for is an agenda of therapy first”.

Repackaging: clinical psychologist Dr Anna Hutchinson says one variant of the gender-affirmative approach may reframe potential coercion as care—for example, when parents are confronted with a choice between ‘a live trans daughter or a dead son’.

Contested connections

Therapy First has come in for some criticism over its choice of presenters. An ethics webinar last year featured Jamison Green, a trans man who had served as president of the World Professional Association for Transgender Health. Of the 2026 conference presenters, Dr Anderson served on the WPATH board—until she resigned over its attempt to stop any repeat of her frank comments to the press. And Dr Edwards-Leeper helped bring to America the puberty blocker-driven Dutch Protocol for the medical transition of minors.

Those connections trouble Pamela Garfield-Jaeger, a licensed clinical social worker. On X last month, she posted: “I want it on record that I am not affiliated with Therapy First. I removed myself from their website over a year ago. I had multiple conversations with the leaders about my disagreements, but they chose to continue on a path that I do not align with.”

It appears she is not alone. Her post generated some agreement in the replies and notched up about 3,500 views.

For Garfield-Jaeger, it is a question of values, or perhaps a lack of clarity about values. Her impression is that Dr Edwards-Leeper still believes that, with the right assessment, some adolescents may benefit from medical transition. (GCN understands that Dr Edwards-Leeper also makes any transition contingent on securing true informed assent or consent.) Dr Edwards-Leeper was a work group member for the adolescents chapter of WPATH’s current Standards of Care. And WPATH, as an organisation, faces accusations that go to its scientific integrity.

Garfield-Jaeger says her wariness has nothing personal about it. She likes a lot of the people involved with Therapy First and has had “positive interactions” with Garcia-Ryan.

She sees herself as pretty flexible, not one to police pronouns or to avoid collaborations just because they fall short of 100 per cent agreement with her views. But as Therapy First evolved, she had hoped it would, in time, set its face against hormonal and surgical transition, which she regards as “medically assisted self-harm”. Instead, she feels, the organisation is platforming the belief that some medical transition is a good thing.

“I used to think that maybe somebody would benefit from the cross-sex hormones and surgeries,” Garfield-Jaeger tells GCN. “But I don’t believe that anymore, now that I know more about the effects—not the side effects, but the effects—of cross-sex hormones and the surgeries, which really are very experimental, especially what they call the ‘bottom surgery’ for both men and women—it’s quite barbaric, in my opinion.”

For avoidance of doubt

Therapy First inherited from GETA the position that “medical interventions for gender dysphoria in children and teens are experimental and should be avoided if possible”, given the lack of long-term evidence and the risk of regret.

“We believe that psychological approaches should be the first-line treatment for all cases of gender dysphoria. Psychological interventions avoid the risks of social and medical transition, and support client autonomy by facilitating deeper self-understanding,” GETA said.

More recently, the values statement of Therapy First was changed. Now it reads that medical interventions for young people “should be approached with the appropriate caution”. Again, there is a nod to the limited evidence base, and this new content also highlights the risk of harm and the fact that “the identities and decision-making capacities of youth are still developing”.

But this updated position has caused some head-scratching.

Garcia-Ryan recognises that the revision “has caused some confusion and concern, and we have taken that in. We are reviewing the language [on the website] and the values statement to see if we can wordsmith things in such a way that makes it a little bit clearer what our intentions were.”

Meanwhile, two changes to Therapy First’s FAQs webpage have already been approved. First, an explanation of what is meant by “appropriate caution”. Citing systematic reviews that show the shortcomings of the research data, the new entry says “there is insufficient evidence to recommend hormonal and surgical interventions for gender-distressed children and youth. Clinical decisions—in both mental health and medical contexts—should be guided by the responsibility of healthcare providers to safeguard the young person from unnecessary harm”.

The second change addresses the question of Therapy First’s proximity to WPATH, which is a hybrid professional-activist body. Garcia-Ryan says his organisation’s references to WPATH—like those to the treatment recommendations of other guidelines—are limited to mainstream mental healthcare, not medical interventions, and focused on adolescents with gender dysphoria.

The WPATH recommendations, as understood by Therapy First, “specify that clinicians working with gender-diverse youth should have training and expertise in both gender identity development and general child, adolescent and family mental health across the developmental spectrum. This includes understanding typical and atypical development, family dynamics, and broader youth mental health issues.”

Notwithstanding these online content tweaks, Garcia-Ryan insists that in the real world the mission of Therapy First remains the same: to raise the quality of mental health care for youth experiencing gender dysphoria. However, the articulation of its values statement has shifted.

“Therapy First is balancing multiple imperative values: the safeguarding of our patients from medical harm, therapeutic neutrality and patient autonomy,” he says.

And he says the “references to established standards demonstrate that Therapy First is consistent with what the mainstream mental health establishment embraces for the mental healthcare of youth experiencing gender distress”.

But does Therapy First risk reputational damage if it is seen to be closer to WPATH than is the case? “It’s a good question,” Garcia-Ryan says. “I would say that we’re not worried about that.”

Is there something naive or utopian about fixing upon just those sections of the WPATH guideline that contain unexceptional mental health recommendations? After all, WPATH and the other guidelines and policies under its influence have not prevented the hasty medical transition of minors in significant numbers.

Garcia-Ryan says: “We train clinicians in accordance with the established standards of care. And when we say that, we’re referring to the legal standard of care for this population. We’re not referring to WPATH Standards of Care, which is a clinical guideline the very title of which can be very confusing.”

However, he says, the WPATH guidelines do have relevant recommendations for the elements of competent clinical practice with gender dysphoric youth. Therapy First also references related documents from the American Psychological Association, the American Psychiatric Association, and the American Academy of Child and Adolescent Psychiatry.

Garcia-Ryan says that each of the components of good practice in mental healthcare has its own standards that “contribute to whether the overall care provided meets the applicable legal standard of care”.

The term “care”, he says, is “broad and includes assessment, diagnosis and formulation, informed consent, treatment of co-occurring conditions, documentation, attention to developmental and family context, and the exercise of clinical judgment, among others”.

The problem, Garcia-Ryan says, is not that clinical guidelines lack recommendations consistent with the legal standards of care. “It’s that, even though the legal standard for mental healthcare for gender-distressed adolescents is indeed reflected in these guidelines, the legal standard of care is still not being met in practice.”

“There is general confusion around how standards are set,” he says. “Ultimately, the courts determine what constitutes the standard of care and whether they were met.”

Sub-standard

Garcia-Ryan invokes the courtroom standard of care as set out in a landmark case awarding US$2 million in damages to American detransitioner Fox Varian. She had undergone a double mastectomy as a minor with mental health problems, journalist Benjamin Ryan reported in February for The Free Press. Lawyers for Varian’s psychologist and surgeon argued that WPATH’s treatment recommendations did not represent the legal standard of care against which the adequacy of a practitioner’s conduct is measured in court.

“The Varian verdict also clarified that affirmation of an adolescent’s current identity and the facilitation of the adolescent’s stated treatment goals do not constitute the legal standard of care for this population,” Garcia-Ryan says. “A clinician can be negligent in how identity is approached and discussed, just as a clinician can be negligent in other aspects of assessment and treatment.”

He says the legal standard of care is both a high bar for clinicians to meet and what, in any event, should be the norm: psychotherapy as the first-line treatment, a rigorous mental health assessment, and differential diagnosis to identify and treat co-morbid conditions with attention to the unique circumstances of each individual.

He says Therapy First is predominantly American in its focus, but also references the Cass Review and international guidelines from England’s National Health Service, Sweden and Finland. (The latter two documents outperformed WPATH’s Standards of Care in a global evaluation of guidelines commissioned by Dr Cass.)

“Therapy First has made consistent efforts to ensure Cass-aligned clinical training exists in the US,” Garcia-Ryan says.

He says that his organisation does not support bans on medical gender-affirming care for minors. Nor does it have a position on the utility of the term rapid-onset gender dysphoria, which has been popularised to capture the phenomenon of teenagers who, with no childhood history of gender nonconformity, suddenly declare a trans identity amid potential influence from social media and peer groups.

However, Garcia-Ryan says Therapy First does work with those clients “who have adolescent-onset gender dysphoria for a whole host of different reasons”.

In any event, he believes that mental health practitioners should not be making judgment calls on eligibility for puberty blockers, cross-sex hormones or surgery.

“Many therapists, including myself, feel strongly that medical determination is out of the scope of the therapist and that we have to get our profession focused on the work of therapy again,” Garcia-Ryan says.

“We safeguard [gender-distressed youth] by working to raise the mental health standards for this population, which really requires a diverse range of professionals to come to the table and talk to one another.”

Cautionary tales

If, however, there are parents considering blockers for their child, Garcia-Ryan says the role of the therapist is to explain what “appropriate caution means”, and to set out the concerns arising from systematic reviews as well as the implications of an adolescent’s developmental stage.

Garcia-Ryan himself has experience with both transition and detransition. He says he did not get “developmentally informed, good psychotherapy” when he was affirmed at age 15.

“My personal experience played a role in my stepping into this work, but the work [of Therapy First] isn’t about me, and it shouldn’t be, as it shouldn’t be for any therapist,” he says.

He emphasises that practitioners helping clients in the therapy room must put aside their own beliefs and opinions, but says his own experience partly explains his decision to take on a leadership role with Therapy First.

“I was a shy, gender-nonconforming boy,” Garcia-Ryan says. “It’s not in my temperament, or really in my nature, to be the face of and the voice of an organisation that is in the centre of one of the most controversial issues, and [so, to step up as president], would have required me to feel I had a sense of duty and obligation.”

Therapy First supports US laws prohibiting conversion therapy that seeks to change sexual orientation or gender identity, according to its FAQs page. “However, misinterpretation and misuse of these laws has led to a chilling effect that has limited the care available to this population, and we hope this will change as the laws are more accurately understood and applied.”

Different strokes

One marker of difference between Therapy First and the group Genspect is the latter’s fundamental critique of conversion therapy prohibitions.

Genspect’s founder, Irish psychotherapist Dr Stella O’Malley, says “the mental gymnastics surrounding ‘conversion therapy bans’ have paralysed clinicians.

“They are no longer permitted to ask why a girl hates her body, or why a boy spends hours in the bathroom obsessively removing every hair from his body in a desperate attempt to feel female.

“Such questions are now labelled ‘conversion’, while approving mastectomy or castration is celebrated as affirmation.”

Genspect challenges WPATH’s depathologisation program with its own REPATH campaign: a “re-psychopathologization of transgender ideation and the drive to medically transition”, which Genspect categorises as an “extreme overvalued belief”. (This framing, first announced in September 2025, has been predictably attacked by trans rights advocates. Genspect promptly acknowledged some unease “about our choice of language”.)

Garcia-Ryan points out that Therapy First is “a clinical organisation, not an advocacy organisation”. Genspect is a vigorous advocate not afraid to ruffle feathers.

Dr O’Malley, who was a co-founder of GETA, tells GCN it is “entirely understandable that, as the movement matures, different organisations develop in different directions. I welcome this; it brings greater clarity to a complex issue.

“When I co-founded GETA and helped write its original principles, our stated position was one that ‘avoided medicalisation’. Therapy First has since moved from avoiding medicalisation to stating that ‘medical interventions should be approached with the appropriate caution’.

“This represents what I call the ‘third way’, or the Hilary Cass approach: it rejects automatic affirmation and restores psychotherapy as the first response, while retaining medical transition for a carefully selected minority. In that context, inviting clinicians such as Erica Anderson and Laura Edwards-Leeper [to present at the upcoming conference] is consistent with Therapy First’s mission; they are prominent representatives of that position.”

“There remains considerable common ground between Genspect and Therapy First. Both reject the affirmative model and recognise the need for serious psychological care,” Dr O’Malley says.

“The difference concerns where that care may lead: Therapy First retains medicalisation as a possible treatment path; Genspect does not.

“It is better to acknowledge that distinction clearly than to pretend that everyone challenging gender-affirming care holds precisely the same position.

“This is especially important for parents of trans-identified children, who need to understand whether a therapist is offering a genuine alternative to medicalisation or simply a more cautious route towards it.”

Pitfalls of compassion

To Garfield-Jaeger, it seems that Therapy First’s policy is “some transition is OK and if you don’t affirm, then you’re not compassionate”.

“They seem to be marketing themselves as a more compassionate bunch, which is really how we all got into this mess in the first place,” she says.

“It’s like a kindness umbrella, a shield to allow for harmful behaviour, allowing these kids and these adults to go down these really painful and destructive paths of living a lie and destroying their bodies.

“It’s like what’s happening to Therapy First is literally what happened to the rest of our institutions. Therapy First was supposed to be the exception, but they’re actually just going down the exact same path, which is being captured by these WPATH therapists.”

Hard ‘No’ to medicalisation

Genspect’s Dr O’Malley says her organisation believes that “children and adolescents should receive psychologically informed care and should never be placed on a medical pathway involving puberty blockers, cross-sex hormones or surgery.

“There is no reliable evidence that the benefits of these interventions outweigh their serious and potentially irreversible harms.

“We also believe that, while adults are free to seek elective body modification, personal choice does not make an intervention healthcare, and consumer demand is not a clinical indication. Clinicians cannot justify providing inadequately evidenced interventions simply because patients request them.

“Procedures that remove healthy organs, impair bodily functions or create lifelong medical dependency should not be offered through hospitals or clinical services—or funded by public healthcare systems—as treatments for psychological distress. The fact that many people who have medically transitioned continue to function well does not alter this position.

“People with anorexia may also remain outwardly functional, as may otherwise successful and well-adjusted people who self-harm. That does not make weight-loss drugs an appropriate or acceptable treatment path for anorexia, nor does it mean that clinicians should facilitate self-harm [as] healthcare, simply because the individual requests it.

“Adults may seek these medical interventions, but clinicians should not be free to provide them and call this healthcare. Such provision resembles a ‘buyer beware’ consumer model rather than medicine’s duty to diagnose carefully, treat illness, restore function and avoid unnecessary harm.

“Of course, differences of sex development, sometimes called intersex conditions, are separate physical conditions. Medically necessary treatment for them is legitimate healthcare and should not be conflated with transgender medicine.”