Frequently Asked Questions

What is Therapy First?

Therapy First is a U.S. based nonprofit organization dedicated to advancing the field of mental health for children, adolescents, and young adults experiencing gender dysphoria. The organization was founded in 2021 in response to concerns that clinicians were not offering gender questioning youth adequate mental health care. Our mission is to raise the quality of care accessible to these young people and to drive systemic improvements within the mental health field necessary to meet their needs. The organization adheres to established standards of care and works to ensure that clinicians are trained in and consistently follow the guidelines set forth by major mental health associations, providing care that is developmentally appropriate, evidence-informed, and aligned with professional best practices.

Why is Therapy First needed?

Therapy First exists to ensure that children, adolescents, and young adults experiencing gender dysphoria receive mental health care that is developmentally appropriate and meets established professional standards. It is important to note that clinical experience with mature adults does not adequately translate to work with youth. Adult models of care cannot simply be applied to children and young people, which is why specialized training is necessary.

The American Psychological Association, the American Psychiatric Association, and the World Professional Association for Transgender Health (WPATH), have long emphasized the need for therapy first for youth experiencing gender dysphoria. WPATH Standards of Care Version 8 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.

Therapy First addresses this need by training clinicians to meet these standards, equipping them with the expertise in gender-diverse populations and developmental psychology necessary to provide safe, evidence-informed care. By doing so, Therapy First also helps ensure that the public has access to care that aligns with professional best practices and the developmental needs of youth.

What does therapy first mean in practice?

In practice, therapy first means providing comprehensive mental health care as the first-line approach for young people experiencing gender dysphoria. This involves clinicians developing a full psychological understanding of each young person by making thorough assessments, conducting differential diagnosis of co-occurring conditions, and tailoring therapeutic interventions to their individual needs. A therapy first approach to care also supports age-appropriate milestones, and is guided by principles of developmental psychology, the best available research, and established professional standards.

How does Therapy First promote the standards of care established by leading mental health associations?

Therapy First promotes and implements the standards of care established by major mental health associations by training and supporting clinicians to provide comprehensive assessments, address co-occurring mental health and developmental concerns, and deliver ongoing therapeutic care that helps young people explore their identity and achieve developmental milestones. This is consistent with guidelines from the American Psychological Association, the American Psychiatric Association, and the World Professional Association for Transgender Health, whose established standards of care have always recommended therapy first for this population.

The American Psychological Association’s Guidelines for Psychological Practice with Transgender and Gender Nonconforming People note that adolescents with gender identity concerns often present with complex psychological challenges, including co-occurring mental health conditions, and emphasize supporting developmentally appropriate identity exploration. The World Professional Association for Transgender Health, in its Standards of Care Version 8, highlights the importance of therapy that promotes self-discovery and individualized care, and the American Academy of Child and Adolescent Psychiatry, in its 2024 policy statement, recognizes the importance of open exploration of identity and individualized care that is developmentally thoughtful.

How do professional guidelines distinguish between care for gender dysphoric youth and adults?

Clinical work with youth experiencing gender dysphoria is meaningfully distinct from clinical work with gender dysphoric adults due to the ongoing psychological, cognitive, and emotional development that takes place during childhood, adolescence, and young adulthood. Exploration, as part of individualized, developmentally informed assessment and therapy, plays a central role in the mental health treatment of gender dysphoric youth. This is affirmed by major professional organizations and reflected in their current clinical guidelines.

The American Psychological Association’s Guidelines for Psychological Practice with Transgender and Gender Nonconforming People emphasize that adolescents may present with particular complications. The guidelines note that adolescents with gender identity concerns “bring their own set of unique challenges,” including those with “a late-onset (i.e., postpubertal) presentation of gender nonconforming identification, with no history of gender role nonconformity or gender questioning in childhood.” The American Psychological Association recognizes that many gender-questioning adolescents “also present with co-occurring psychological concerns, such as suicidal ideation, self-injurious behaviors, drug and alcohol use, and autism spectrum disorders.” The guidelines also describe how adolescents “can become intensely focused on their immediate desires,” which may lead to difficulty tolerating delays in medical intervention. This, in turn, can present clinical challenges in “assuring that adolescents are cognitively and emotionally able to make life-altering decisions,” such as pursuing medical transition.

Similarly, the American Psychiatric Association, in A Guide for Working with Transgender and Gender Nonconforming Patients, states that “gender dysphoric symptoms may be the primary focus of treatment,” but warns clinicians not to overlook the possibility that “other psychiatric symptoms may need to be treated first depending on severity.”

Similarly, The World Professional Association for Transgender Health (WPATH), in its Standards of Care Version 8, underscores the importance of individualized, comprehensive care. WPATH states that there is “no one particular pace, process, or outcome that can be predicted for an individual adolescent seeking gender-affirming care,” highlighting the wide variation in how identity develops over time. To address this complexity, WPATH recommends that healthcare professionals “undertake a comprehensive biopsychosocial assessment of adolescents who present with gender identity-related concerns and seek medical/surgical transition-related care,” and that such assessment should occur “in a collaborative and supportive manner.”

WPATH further states that certain mental health requirements should be met before the initiation of gender-affirming medical interventions, particularly when mental health challenges may interfere with diagnostic clarity or informed consent. The guidelines emphasize that “mental health difficulties may […] complicate the assessment of gender development and gender identity-related needs,” and that clinicians must be able to “differentiate gender incongruence from specific mental health presentations,” such as “obsessions and compulsions, special interests in autism, rigid thinking, broader identity problems, parent/child interaction difficulties, severe developmental anxieties (e.g., fear of growing up and pubertal changes unrelated to gender identity), trauma, or psychotic thoughts.” WPATH concludes that “mental health challenges that interfere with the clarity of identity development and gender-related decision-making should be prioritized and addressed.”

These guidelines emphasize the importance of clinical care for gender dysphoric youth that is grounded in developmental psychology, supports identity exploration and development, includes comprehensive assessment and differential diagnoses, and treats co-occurring conditions.

Therapy First promotes adherence to these best practices.

Does Therapy First promote “gender exploratory therapy”?

No. While “gender exploratory therapy” as a term has gained traction in public discourse, we are not aware of an established therapeutic modality by that name and, to our knowledge, no such model has been formally developed or is in professional practice as a distinct approach to therapy. Consequently, it is not a model of mental health treatment developed by or promoted by Therapy First and we have not issued any continuing education programs, published materials, or clinician training using this term. Attributing the term “gender exploratory therapy” to the approach promoted by Therapy First is inaccurate.

Why did the organization change its name from the Gender Exploratory Therapy Association to Therapy First?

In 2023, our organization rebranded from the Gender Exploratory Therapy Association to Therapy First to better convey its mission and to curtail public confusion regarding the treatment approaches it endorsed. The original name had been selected in response to concerns that clinicians in the field were not adhering to established standards of care regarding the importance of identity exploration when working with gender-questioning and gender-variant youth and concerns that clinicians were not providing these youth adequate care as a result.

How does Therapy First incorporate trans and LGBT perspectives into its work?

Therapy First is proud to be a trans inclusive organization. Our leadership, membership, and programming consists of professionals of trans experience, including our Executive Director. We actively integrate the input of trans professionals and consider their experiences and perspectives in shaping our work. In addition, Therapy First’s leadership and membership include LGBT professionals more broadly. Therapy First strives to provide training and guidance that is respectful, supportive, and responsive to the young people and families we serve, and our efforts to include LGBT professionals in decision making and program development ensures that our training and continuing education offerings are informed by lived experience and the values and concerns of those we seek to serve.

What is Therapy First’s position on conversion therapy?

Therapy First is against conversion therapy, an unethical practice that has been condemned by all major mental health associations. We reject any approach aimed at changing an individual’s identity. We have been clear and consistent about our values in this regard and stand firmly behind them – a rejection of Gender Identity Change Efforts (GICE) and Sexual Orientation Change Efforts (SOCE), a steadfast commitment to providing care for youth experiencing gender dysphoria that upholds dignity and respect, and the importance of care that is individualized and which facilitates identity exploration and development without a predetermined outcome.

Assessing and exploring the potential factors contributing to the development of gender-related distress is a crucial component of mental health care for young people experiencing gender dysphoria, as their identities are still actively in formation. This is supported by professional standards set forth by the World Professional Association for Transgender Health, the American Psychological Association, and the American Psychiatric Association.

WPATH’s Standards of Care Version 8 explicitly states that therapy “carried out in the context of supporting an adolescent with self-discovery is not considered reparative therapy, as long as there is no a priori goal to change or promote one particular gender identity or expression.” Similarly, the American Academy of Child and Adolescent Psychiatry, in its policy on conversion therapy, affirms that it “in no way detracts from the standard of care, which requires that clinicians facilitate the developmentally appropriate, open exploration of sexual orientation, gender identity, and/or gender expression, without any predetermined outcome.”

Therapy First fully aligns with these standards.

What is Therapy First’s position on laws banning conversion therapy?

Therapy First supports current U.S. conversion therapy laws that prohibit any practice or treatment by a licensed mental health professional that attempts or purports to change an individual’s sexual orientation or gender identity, including efforts to change behaviors or gender expressions or to eliminate or reduce sexual or romantic attraction or feelings toward individuals of the same sex.

Therapy First takes the position that, when read contextually and accurately, these laws support a therapy first approach. Therapy First sees these laws as both protecting young people from coercive and harmful practices and supporting therapists to provide comprehensive, developmentally informed care to gender dysphoric youth. The laws are clear that they do not prohibit therapeutic care that offers “acceptance, support, and understanding,” or that facilitates a young person’s coping, social support, identity exploration, or development.

Therapy First views this as aligned with its commitment to providing comprehensive mental healthcare and supporting developmentally informed identity exploration.