My face when encountering Therapy First.
As a therapist that works with gender-nonconforming and transgender youth, I’m always on the look out for new research to read and new organizations to join.
In my search, I discovered an ostensibly pro-gender-therapy, but anti-gender-therapy organization that promotes autonomy by discouraging personal choice.
This confusing organization calls itself “Therapy First.”
The goal of “therapy for gender dysphoria” is…just what you do?
Their website’s tagline is “Psychotherapy as first-line treatment for gender dysphoria.” Which…is just true? People with gender dysphoria often need support, and that goes doubly for kids. I love therapy. That’s my job - making teens feel seen and supported.
When gender affirming care was legal for minors in TX and NC, all the clinics I worked with wouldn’t even book an appointment if the family wasn’t already working with a therapist. Therapy has always been necessary, aka….first.
“Mine! All mine!” - Dentists, probably.
Saying “Therapy first” is like saying “Dentists first. Stop stealing teeth from children - take them to a dentist instead.” Who is doing that? What are you talking about?
No parents are randomly stealing all of their children’s teeth as an alternative to dentistry. No parents are taking their children to get gender-affirming care without seeing a therapist first.
Decoupling gender care from therapy is an issue that doesn’t exist, never existed, and no one is proposing it should exist.
I am basing the above statement on my decade of experience working with trans youth in the south. In my professional experience, not once have I ever seen or even heard of medical intervention without therapy first. I’ve never heard it proposed or discussed as an option.
How I imagine therapists react to my membership request.
Wait, should I join this group?
I mean, I’ve been practicing in the area of gender care for teens and young adults for a decade. I’ve always been the first line of support.
If “therapy first” is how gender affirming care works, is this a group for experienced, supportive therapists like me?
Oh…I get it. Therapy First seems to think that transgender people don’t exist.
Not where transgender people come from.
I went over to their “Membership Statement” to see if this was an organization for me. Again, therapy is always first. It should be for affirming therapists like me.
One of the core logical proofs of this work is the following:
If transgender adults exist, and we know adults come from children, then transgender youth exist.
Trans people don’t spring from bamboo shoots or hatch from golden eggs. They were once children, who have since grown into teens, who grew into adults.
Teens grow into adults. Trans teens can grow into trans adults.
Does every transgender person know they are transgender as a teenager? No.
Gender incongruity often feels weird and complicated, especially if it’s something you don’t want to admit to yourself.
Do zero transgender people know they are transgender as teens? No.
When kids aren’t listened to, they pivot to making signs.
Some teens are able to understand and articulate their complex feelings about gender incongruity - especially when they have a supportive therapist who is open to the idea that maybe, possibly, there’s a slight chance that the teenager is telling the truth.
Much like this dog, all I really care about is treats.
I literally do not care whether anyone is transgender or not.
My therapy practice’s official tagline is “It doesn’t have to suck forever.”
My practice’s unofficial tagline is “Fewer dead kids.” Anything that brings me closer to this goal is good in my book.
I do not care if 0% of the youth that start therapy with me end up believing they are transgender. The percentage of transgender kids is irrelevant and unimportant to me.
All I want is for teens to know themselves better, feel like they’re okay, and know that they can be loved.
Prominent medical organizations agree: it is imperative that therapists understand the difference between self-loathing and slaying
Seeing a therapist who doesn’t think they’re lying, crazy, or a “self-loathing homosexual” is important to a teen’s sense of self-esteem. I’m not just saying this. Julia Serano has volumes of work reviewing the benefits of affirming care (and the damaging approaches of groups like “Therapy First.”
And it’s not just me! The following groups are just some of the few organizations for the protection of the lives and health of children that believe transgender people can exist under the age of 18:
American Academy of Pediatrics (2018; reaffirmed in 2023)
American Medical Association (2022)
Endocrine Society (2017)
Pediatric Endocrine Society (2017)
I don’t know if every teenager who shows up on my virtual doorstep is trans, but I’m open to the possibility that they could be.
Back to the Membership Statement
The long list of beliefs falls into the following categories:
Statements that are uncontroversial and true.
ex: therapy is first, therapy is good.
Statements that are not accurate.
ex: “Given the lack of long-term, peer-reviewed, longitudinal evidence and the risk of regret, medical interventions for gender dysphoria in children and teens are experimental and should be avoided if possible.” Again, this comprehensive review of research on gender-affirming care (a 35 minute read, according to Medium!) and the position statements linked above shows this to not be true.
Statements that are true in their meaning, but not in their application.
ex: “We respect client autonomy and do not impose our own beliefs, values, opinions, ideology, religion, or goals on clients.”
Therapy First doesn’t seem to understand “autonomy.”
We want to nurture our children’s independence and self-efficacy, just not when it comes to gender identity? Got it.
Autonomy refers to the ability to make choices for yourself. It’s an important element of everyone’s life, from children to adults. Child development experts suggest allowing your children to choose between two options instead of telling them what to do. Gerontologists underscore the importance of including the elderly in decisions about their own health.
To give someone autonomy, you have to believe that they are capable of understanding their own needs - that they are telling the truth.
Therapy First explicitly undermines the concept of autonomy with the following statements (bolding mine):
It is extremely difficult to determine if a gender identity experienced during childhood and adolescence will remain fixed into adulthood. Because identity remains in flux during adolescence, clinicians should be very circumspect about recommending therapies that result in irreversible changes.
Young people may not have the capacity to fully comprehend the impact of gender transition and the treatments they desire.
Same-sex attracted youth are often gender nonconforming and may experience distress as they come to terms with their sexual orientation. Gay, lesbian, and bisexual youth may need help and support to accept themselves as they are.
My face whenever a teenager tries to tell me they understand anything about their own experience. I’m the therapist here!
I do not disagree with any of these statements on the basis of their literal meaning, but on the implications about the inability for youth to ever accurately assess whether they are trans.
Identity is in flux during adolescence! But would Therapy First consider sexual orientation part of this flux? Would they think that because identity is evolving, a teenager would not be able to know whether they are straight or gay?
I’m guessing not, because the final statement quoted acknowledges the existence of gay, lesbian, and bisexual youth. Those things can be known, despite the growth period of adolescence it seems, just not gender.
You’ll get bodily autonomy eventually - what’s the rush? Rights and dignity are for adults only!
The statement about capacity for understanding and clinicians being circumspect, on its face, does not seem suspect. Teenagers do not have the capacity to understand the consequences of some things and adults working with teens should hold boundaries. The implication of these statements is different from the words.
These statements imply that teens are unable to understand what they need, and clinicians need to therefore make the decision for them - the opposite of recognizing autonomy.
What is Therapy First’s Goal?
Here’s a summary of what Therapy First has said:
It’s not conversion therapy, we just think there’s some pathological reason why they all feel this way? Uh-huh.
Therapy should be the first-line treatment (no one has ever suggested otherwise to me in all my years of being a therapist)
Gender-affirming care is unresearched and outdated (untrue - see this review of research on affirming care and the recent position statements of prominent organizations above, some from 2024)
Teenagers are unable to make choices for themselves regarding gender and therapists should assume teens are confused and incapable of comprehending medical intervention, but teens can understand their own sexuality but might secretly have more distressing sexuality that therapists should look for instead because gender is too confusing for teenagers to understand (what. Again, Julia Serano has compiled research debunking the idea of “social contagion” causing transness, which closely relates to the idea that teens can understand their sexuality, but not gender)
These statements are completely out of step with my decade of experience working with children (ages 12 and up) who are gender creative, gender nonconforming, gender questioning, and transgender.
I have to assume that the proponents are deeply confused (as I was, reading their website) or are intentionally using lies and propaganda to spread an anti-trans narrative.
Regardless of what their motivation is, I am less interested in interpreting their actions than I am in setting the record straight:
Love and a pony. What future could be better than this?
Trans youth exist. Trans youth should be believed.
If we want teens to survive to adulthood, we need to make a world that they can see themselves living in.
Kimberly Vered Shashoua, LCSW, is a therapist who works with transgender youth, gender-nonconforming youth, and any other teens who need a safe space.
Vered sees patients virtually in Texas and North Carolina, and offers Continuing Education programs to therapists and other professionals all over the United States.
Vered would much rather be seeing patients than writing blogs and being an advocate; but, unfortunately, that’s not the state of transgender rights in the south.