Gender Dysphoria in Teens: What Parents Should Know

Summary

The debate over gender and young people looks like a war with two clear sides. Paul Garcia-Ryan sees an illusion of sides.

Paul Garcia-Ryan is a licensed clinical social worker and the president of Therapy First, a nonprofit focused on raising the standard of care in youth mental health. In New York City he works with young people experiencing gender dysphoria and their families, and with trans adults. He identified as a woman from age 15 to age 30 and trained as a psychotherapist at a leading gender clinic in New York City. What he saw once younger patients began arriving in his own practice, paired with other factors, led him to see his own history in a new light and to choose to detransition.

In this conversation, he explains how the field has moved from prioritizing a mental health model to prioritizing a medical model, and why he believes therapists so often talk past each other. The word affirm is his clearest example. Most therapists, he says, hear it as offering emotional support and encouragement. The concern many clinicians raise is the other dictionary meaning: agreeing that a young person's current identity is who they are and always will be. Same word, different definitions, and a lot of apparent disagreement that he argues is not really there.

Garcia-Ryan also describes identity formation as something that has always unfolded in conversation with a young person's environment, and how algorithms and social media now shape that environment in ways no earlier generation experienced. For parents, his advice is to stay with a child's distress, however scary it feels, and to avoid locking horns. For clinicians, it is to hold a young person's identity with an open palm. He closes with a call for the mental health profession to come together, and for leaders in the field to step up.

Key takeaways

Garcia-Ryan argues the debate over gender and youth mental health is less divided than it looks. In his words, there is an illusion of sides, and he believes there is a lot more agreement among therapists than disagreement.

Much of the apparent disagreement is about language. He says most therapists hear the word affirm as offering emotional support and encouragement, while the concern many clinicians raise is affirming in the sense of agreeing that a young person's current identity is fixed and will never change.

His illustration: if he called 100 therapists and asked whether they are affirming, he expects 90% would say yes. If he asked those same therapists whether they are comfortable greenlighting a medical intervention for a minor, he expects 80% would say no.

He describes the field as having moved from prioritizing a mental health model to prioritizing a medical model. He calls therapy before any medical intervention the established standard of care, which is where Therapy First takes its name.

Gender dysphoria and trans identity are not the same thing, he says. Gender dysphoria can resolve without medical intervention, and a young person whose dysphoria resolves may still identify as trans.

His advice to parents is to stay with a child's distress, however scary it is, try to understand it, and resist locking horns. He also encourages parents to go to therapy themselves. At Therapy First, he says, the family is the patient.

Terms defined

Plain-language definitions for the ideas in this episode. Structured for search and AI answers.

detransition noun · gender

Stopping or reversing a gender transition, whether medical, social, legal, or some combination.

In this episode: Garcia-Ryan's own story. He transitioned and lived as a woman through his 20s, then chose to detransition at 30.

gender dysphoria noun · mental health

A diagnosis in the DSM that describes clinically significant distress tied to an incongruence between a person's experienced gender and, in the manual's terms, their assigned gender.

In this episode: Garcia-Ryan stresses that it is not synonymous with trans identity, and that it can resolve without medical intervention.

affirm verb · two definitions

In the dictionary, both to agree with or declare something true, and to offer emotional support and encouragement.

In this episode: His example of therapists using the same word with different definitions, and talking past each other as a result.

therapy first noun · standard of care

An approach in which psychotherapy comes before any medical intervention for a young person experiencing gender dysphoria.

In this episode: What Garcia-Ryan calls the established standard of care, and the name of the nonprofit he leads.

identity formation noun · developmental psychology

The process, central to adolescence and extending into the early 20s, of working out who you are and where you belong. Garcia-Ryan describes it as always unfolding in co-construction with a young person's environment, society, and relationships.

In this episode: Why he says algorithms and social media now play such a large role in how young people form their sense of self.

Notable quotes

Lines worth keeping, verbatim from the episode.

I actually don't think that there are sides. I think that there's an illusion of sides.

Paul Garcia-Ryan 01:01

I think there's actually a lot more agreement amongst therapists than disagreement.

Paul Garcia-Ryan 31:41

Every therapist working with a young person experiencing gender dysphoria ought to hold a young person's gender identity with an open palm.

Paul Garcia-Ryan 37:08

Therapists are talking past one another, using the same words, but hearing different meaning and hearing different definitions with those words.

Paul Garcia-Ryan 41:16

Gender dysphoria is not synonymous with trans identity.

Paul Garcia-Ryan 41:36

At Therapy First, we often say that the family is the patient.

Paul Garcia-Ryan 25:42

A young person's algorithm right now is constantly feeding them content that shapes their identity formation.

Paul Garcia-Ryan 20:01

It's an all hands-on-deck moment for the mental health profession. And we especially need leaders in the field to step up and be part of this moment.

Paul Garcia-Ryan 52:57

The guest

Paul Garcia-Ryan

Licensed clinical social worker · President, Therapy First

Paul Garcia-Ryan is a licensed clinical social worker and the president of Therapy First, a nonprofit focused on raising the standard of care in youth mental health. He identified as a woman from age 15 to age 30, then chose to detransition, and he trained as a psychotherapist at a leading gender clinic in New York City.

Paul now works with young people and their families, and with trans adults. He argues that the debate over gender and young people has a lot less to do with sides than the culture war makes it look.

therapyfirst.org → Profile & episodes

Frequently asked

Straight answers to the questions this essay raises. Open by default, structured for search and AI.

Who is Paul Garcia-Ryan? +

He is a licensed clinical social worker and psychotherapist in New York City and the president of Therapy First. He works with young people experiencing gender dysphoria and their families, and with trans adults. He identified as a woman from age 15 to age 30 and later chose to detransition.

How do I know if I'm transgender? +

No quiz or checklist can answer that for you, and nothing on this page is meant to. What Garcia-Ryan describes is that adolescence, a period that stretches into the early 20s, is a time when identity is still forming, and that it always forms in conversation with the world around you, including what your feeds show you. His view is that a good therapist helps you explore what you are feeling with an open mind instead of deciding the answer for you. If you are questioning, talk with a parent or another adult you trust, and ask to see a licensed therapist. If you or someone you love is struggling or thinking about self-harm, call or text 988 to reach the 988 Suicide & Crisis Lifeline, any time.

My child says they might be transgender. What should I do? +

Garcia-Ryan's advice is to stay with your child's distress, however scary it is, and to really try to understand it rather than locking horns. He says some of the worst problems come when parents fight with their child about the identity they are expressing, because the child's underlying feelings end up dismissed. He also encourages parents to go to therapy themselves and to consider family therapy. This is one clinician's perspective, not medical advice, so reach out to a licensed professional for your family's situation. If you or someone you love is struggling or thinking about self-harm, call or text 988 to reach the 988 Suicide & Crisis Lifeline, any time.

Is gender dysphoria the same as being transgender? +

No, according to Garcia-Ryan. He says the two are often treated as synonymous but are not the same. Gender dysphoria is a diagnosis, while being trans is an identity. A young person whose gender dysphoria resolves may still identify as trans, and he says some young people who identify as trans do not meet the diagnostic criteria for gender dysphoria.

Can gender dysphoria go away? +

Garcia-Ryan says it can resolve without medical intervention, and that many therapists have not considered that possibility. He also says gender identity can be fluid, especially for young people. How that applies to any one person is something to work through with a licensed professional.

Why are more teens experiencing gender dysphoria today? +

Garcia-Ryan says the young people now arriving at gender clinics are a different group than in the past. Beginning in the early 2010s, he describes a dramatic rise in natal females whose gender dysphoria began in adolescence with no earlier history, most also presenting with co-occurring mental health conditions or neurodevelopmental conditions like autism. His view is that rapid social, cultural, and technological change, including algorithms that constantly feed young people content, has profoundly altered how they form identity.

What does affirming therapy mean? +

It depends on who is using the word, which is Garcia-Ryan's point. Most therapists, he says, mean offering emotional support and encouragement. The concern many clinicians raise is a different meaning: agreeing that a young person's current identity is who they are and always will be. Because the same word carries both definitions, he argues, therapists often talk past each other.

What is the therapy first approach? +

It is an approach in which psychotherapy comes before any medical intervention for a young person experiencing gender dysphoria. Garcia-Ryan calls it the established standard of care. Therapy First is also the name of the nonprofit he leads, which trains therapists and works to raise the standard of care in youth mental health. It is at therapyfirst.org.

What does detransition mean? +

Detransition generally means stopping or reversing a gender transition. Garcia-Ryan lived as a woman through his 20s after a medical, social, and legal transition. He says that what he saw in his own practice, paired with other factors, led him to see his history in a new light and to choose to detransition.

Resources mentioned

Books

The Anxious Generation Jonathan Haidt · 2024 See details →

Get the book

Amazon Bookshop.org

Also mentioned

Nonprofit Therapy First → Framework RESPECT: the seven topics you are not supposed to talk about at work → Episode Dr. Trish Leigh: Miswired by the Algorithm → Parenting & childhood Raising the Next Generation →

Transcript

00:00 Cold open

Ryan Vet · On this episode of The Ryan Vet Show. Because I think there's a lot of misinformation out there on gender, particularly when it comes to children. It's so important to sit down and have conversations so we know and can get to know people behind the story.

Paul Garcia-Ryan · I identified as a woman from the age 15 to age 30. And I spent the entirety of my 20s living as a woman led me to choose to detransition.

Paul Garcia-Ryan · The first pediatric gender clinic in the United States opened in 2007. And do you know what else happened in 2007, the year that the iPhone was introduced?

Paul Garcia-Ryan · A young person's algorithm right now is constantly feeding them content that shapes their identity formation. By 2018, the UK government reported a 4,000% increase in referrals of youth experiencing gender dysphoria.

Paul Garcia-Ryan · I actually don't think that there are sides. I think that there's an illusion of sides.

Ryan Vet · We have more information at our fingertips, and you can even argue that information is knowledge, but so often that information and knowledge lacks the wisdom and experience. The Ryan Vet Show.

01:31 Meet Paul Garcia-Ryan

Ryan Vet · Welcome to another episode of The Ryan Vet Show. I have Paul Garcia-Ryan, who has a great hyphenated last name. You know, Ryan is always a good way to start the show. But I have Paul Garcia-Ryan with me. He leads at Therapy First and just has an incredible story that I can't wait to explore and have this conversation with him. So Paul, thanks so much for being here today.

Paul Garcia-Ryan · Oh well, thanks for having me. I'm really glad to be here with you.

Ryan Vet · Yeah. And Paul, we've had the opportunity over the past several weeks to get to know each other on some conversations and via email. And I think one of the things that I always like to say about the show is my respect framework talks about all the things you're not supposed to talk about in the workplace. So religion, education, sex and gender, politics, economics, communication, and technology. Those are the seven pillars of things that I talk about frequently.

Ryan Vet · And I'm excited to have a conversation today with you to learn from you and to hear your story and just your perspective, because I think there's a lot of misinformation out there on gender, particularly when it comes to children, which is a lot of my focus and trying to help this next generation parents and leaders equip the next generation for the things that they're going to face.

Ryan Vet · So with that said, I would love to just kind of hear what your practice is as a psychotherapist, what you do, and how you work with kids in a world that is inundated with messaging from technology and just a noisy world right now.

Paul Garcia-Ryan · Well, I am a psychotherapist who works with youth who are experiencing gender dysphoria and their families. I also work with trans adults and the broader LGBT community here in New York City. I also run a nonprofit called Therapy First, which is geared towards raising the standard of care, the quality of care that these young people are receiving in the mental health field. And a lot of that involves training therapists, helping therapists and mental health professionals to develop as clinicians, and also to address the polarization that is in this area of healthcare when it comes to the landscape that mental health professionals in particular are navigating.

Paul Garcia-Ryan · Because the higher the polarization is, the more difficult it is to actually ensure that young people are getting optimal mental health care. So I could start maybe by sharing a little bit more about myself, and then maybe we can sort of dive into some specific questions you might have. Where would you like to start?

04:15 Paul's story, in his own words

Ryan Vet · Yeah, I think one of the big things you brought up just now was polarization. And I always run episode topics through a polarization meter, and this topic comes out at about 9.2 out of 10. So it is a polarized issue, but I think as you and I have shared, and even the listeners on my show, as I've shared before, and subscribers to my newsletter, they're divided politically, religiously, and in just about every other category.

Ryan Vet · So I think it's so important to sit down and have conversations so we know and can get to know people behind the story. And so I think your story is powerful and how you came to wanting to help youth in particular today, but a whole community. So could you share a little bit about your story?

Paul Garcia-Ryan · Sure. So I, gosh, where should I start? Well, from a very young age, from early childhood, I had been acutely aware that I was different from my male peers. I was one of those kids who, one of those boys who was like lining up with the girls, and teachers had to correct me and put me on the boys' line. I would put, you know, t-shirts over on my head to emulate long hair.

Paul Garcia-Ryan · And my grandmother would say, Why is he doing that? And my brother would say, Well, he wants to be a girl. And, you know, he was right. And, you know, I was that being very acutely aware of the way in which I was different from my male peers, it was, you know, it was a very challenging and confusing experience. And it was very in a number of ways very distressing.

Paul Garcia-Ryan · It ultimately led me to, in my teenage years, to wonder why I was different. And I ultimately somehow, and I'm forgetting exactly how, 2005. And trans was not an identity, it really wasn't in the zeitgeist, you didn't really hear about young people who were experiencing themselves in this way. But I came to this notion that you could be born in the wrong body, and it really resonated, and it ultimately became probably I would say, you know, the strongest conviction that I had I've ever experienced when it came to how I experienced myself up until that point.

Paul Garcia-Ryan · And so I identified as a woman from ages, from the age 15 to age 30. And I spent the entirety of my 20s living as a woman after a medical, social, and legal transition. And during that time, during my 20s, I trained as a psychotherapist. I'm a technically licensed clinical social worker, and so I went to graduate school to study social work, and I trained as a therapist at a leading gender clinic here in New York City.

Paul Garcia-Ryan · And then I went into private practice, and what I saw and experienced in my practice was I started, you know, I was working with gender dysphoric people, and then I started having gender dysphoric young people come into my practice, and I started to recognize that gender dysphoria was much more complicated than I had ever thought it was, and much more than my training really prepared me for.

Paul Garcia-Ryan · And I also learned during that time, because it really got me thinking a lot and seeking out additional resources for myself as a clinician, but also just to try and understand what was unfolding. And what I learned was that the landscape in this area of healthcare, between when I was experiencing gender dysphoria as a young person and when I entered practice, the landscape had completely changed.

Paul Garcia-Ryan · It was no longer the same cohort that was showing up at gender clinics. And it was something that also really got me to reflect on my own history and start to see my own history in a new light. And that paired with some other factors led me to choose to detransition. And ultimately, I ended up where I am today. One thing led to another, and I started working in a way that is more developmentally grounded than the way I was trained to practice.

Paul Garcia-Ryan · And then I just started to help other therapists do the same thing. And I ultimately was offered the opportunity to step into the role of president for this organization. And it has since evolved in a really meaningful way.

10:10 When the words keep changing

Ryan Vet · Well, Paul, I appreciate you taking the time to tell your story and share just kind of your personal journey because that is what shaped you and the founder of Therapy First on your website. I love her quote, Lisa's quote. You're a natural clinician, she says, able to hold the full complexity of any situation. And it's not because you just went to school, not because you just did got a degree, which are great and important, but it's because you walked it and you understood and you spent the time to reflect personally and understand just your own journey.

Ryan Vet · And you said something interesting just now. Even in 2005, approximately, when you might have started this journey, the words weren't there or the conversation wasn't there. And we've even seen from old English in the early 1900s the idea of transvestite or transsexual changing in the 60s to transgenderism, which didn't really take off. And if you look at certain terms, it didn't even really take off into the 90s or even the early 2000s.

Ryan Vet · There's a study, a word study that looked at the word cisgender that had about a 0.0 occurrence in 2000. And by 2010, we saw that increase sixfold. So a lot of things have changed, even in the journey that you had. What are some of those other changes that you see occurring in culture and society that are impacting young people today?

Paul Garcia-Ryan · Well, it's a really good question. And before I answer that, I think that you just touched upon something that is really important to take note of, which is that in this area of healthcare in particular, terms and language change all the time. And the field of gender-related care evolves very quickly. And so you have to, when you're working in it, you do have to really stay on top of how this area is evolving.

Paul Garcia-Ryan · It evolves rapidly, and that rapid evolution involves the evolution of even just the language that's used. But and so that's I think part of the thing that really sort of trips up a lot of people working in this space is that you know we it can be really hard to keep up with the language and the terms and how the definitions of terms have changed.

Paul Garcia-Ryan · And in a lot of ways, there are terms that therapists are using and they're operating with different definitions based on the clinician using them. And so, in so many instances, what I see are therapists talking past each other. And we can get into that a little bit more, because there's a lot to say about that.

13:12 From a mental health model to a medical model

Paul Garcia-Ryan · But to answer your question about how this area has evolved, I mean, we don't have to get into the weeds about it, but the most important thing to really keep in mind is that over time it's moved from prioritizing a mental health model to prioritizing a medical model. And there, like I said earlier before, the demographics and cohorts of young people experiencing gender dysphoria has also changed.

Paul Garcia-Ryan · And so there was a dramatic rise in natal females with an onset of gender dysphoria in their adolescence, post-puberty, with no prior experience of gender dysphoria or gender nonconformity in early childhood, before adolescence. And this rise in this cohort, the presentation of this new cohort, the rise of gender dysphoria being experienced by this cohort began in I think the early 2010s. And by 2018, the UK government reported that there was there had been a 4,000% increase in referrals of youth experiencing gender dysphoria to their to the largest gender clinic for youth, the Gender Identity Development Service in the UK at the time.

Paul Garcia-Ryan · And so that is something that many clinicians have gotten curious about. How do we what is the reason for that? And how do we help these young people? Because they are unlike, they're not like the young person that I was, and they're experiencing things and developing in a context that I didn't experience. So it's a it's a novel situation, and most of these natal females also were presenting with co-occurring mental health conditions and neurodevelopmental disorders like autism that make the that just make it such that caring for these young people is even more delicate, complicated and complex.

16:20 Growing up before the algorithm

Ryan Vet · You said something really interesting. The idea that what young women or born women and forgive my incorrect terminology today are experiencing, you're saying that is a new issue that was different than even as you and I, because we're just about the same age, you and I were being raised. Could you share what some of those differences are that could be causing some of this?

Paul Garcia-Ryan · Well you know, I think that it has a lot to do with rapid social, cultural, and technological changes in our world. Think about when you were a kid, like how many you didn't have social media, right? You didn't have something like Spotify to or you know, you didn't have algorithms basically like choosing for you what to listen to, what to watch. You had to sort of search it out for yourself.

Paul Garcia-Ryan · You know, youth has always been a developmental period where identity formation is really central, and a process in which the environment plays a big role. So the identity development process for adolescence, which is the period between childhood and adult independence, and it is protracted into the twenties, the early twenties, young adulthood, what's often considered young adulthood. That is something that has always been unfolded in co-construction with your environment, your society, your relationships with other people.

Paul Garcia-Ryan · You look into the mirror of society to sort of reflect back to you a sense of how do I relate to the world that I'm in? How can I, you know, fit in this world? How do I find belonging in this world? How can I make sense and meaning of myself in this world?

Paul Garcia-Ryan · And the interesting thing that I think about a lot is that the first pediatric gender clinic in the United States opened in Boston at the Boston Children's Hospital. And it opened in 2007. And do you know what else happened in 2007, the year that the iPhone was introduced? So you have these like parallel developments occurring right before this new way in which gender dysphoria was starting to be experienced by youth.

Paul Garcia-Ryan · And so that's what comes to mind for me.

Paul Garcia-Ryan · I mean, you know, a young person's algorithm right now is constantly feeding them content that shapes their identity formation. The iPhone, social media, you know, and all these other technological developments, the internet in general, has really profoundly altered the way that young people form identity. And there's really no safeguards to help youth during this developmental stage in an unprecedented environment where there's so much that is actually impacting how their sense of self is shaped.

20:59 Pink shoes, and what parents should know

Ryan Vet · That's good. You know, Jonathan Haidt, his book, The Anxious Generation, talks about his kind of philosophy of the phone-mediated adolescence reshaping identity formation. And I think that's exactly what you're talking to. It's that we live in a different world. And the 2007 marker is a really interesting marker because just five years later is kind of the tipping point that Haidt uses in most of his books, saying that was 2012 was a big tipping point culturally, where we saw all sorts of mental health crises.

Ryan Vet · And you just mentioned that yourself. There are a rise, undeniable. I don't care what side you're on, there's a rise in mental health, especially among youth. And a large part of that is attributed to cell phones and things like that. So what would you do? Because I think, and when we talked before, I said I was gonna change the details of the story just to protect the person.

Ryan Vet · But when I was growing up, there was an individual who and again, changing the details, but let's just say he really wanted pink shoes. And that was the thing he wanted. And his dad chastised him repeatedly for wearing and wanting pink shoes because that was a girl color. And that was you know caused a lot of friction. And he later had different feelings and navigated through some not exactly what you navigated through in your childhood, but definitely influenced the way he went the rest of his life.

Ryan Vet · So now that it's not just happening in the home and your dad's saying you can't wear pink shoes, there's things happening culturally. So what are some of those things that you feel that parents should be aware of and educators should be aware of right now in this world? That's different than even when you and I were raised.

Paul Garcia-Ryan · Yeah, it's a really that's a really good question. Well, I would say just let them have the pink shoes in that instance.

Paul Garcia-Ryan · But, you know when it comes to how parents can better support young people navigating gender dysphoria, I think what I would say is that the parent best helps their child by being with the distress that their kid is experiencing, no matter how scary it is, and really trying to understand it and resisting getting into sort of locked, you know, locking horns with your kid, resisting fighting it, which often occurs because the whole family can get dysregulated because I believe the medical interventions are just hovering over the family's heads at all times, you know, and this field is operating in a way that is kind of rogue.

Paul Garcia-Ryan · You know, therapists are not very often, as far as what as far as I can tell, following the established standard of care, which is therapy first before medical intervention. And so everyone is the family is often put in a position that is such that the family gets very dysregulated. And some of the worst problems come about when parents are fighting with their kid about the identity that their child is expressing, the medical interventions that their child is saying that they want to pursue.

Paul Garcia-Ryan · And it's those problems come about because they lead to the underlying feelings of this young person being dismissed. I would also say that you parents really support their kid by being willing to go to therapy themselves and doing family therapy.

Paul Garcia-Ryan · At Therapy First, we often say that the family is the patient. And depending on the situation, we'll often have one therapist working with the kid, and then another therapist working with the parents, and then another therapist working with the family so that the whole family system gets what it needs to be able to really support this young person.

26:15 Therapy first, and how the field has shifted

Ryan Vet · You said this a few times, and I want to unpack it a little bit further, the difference between therapy or intervention in a counseling setting versus medical intervention. And you have alluded to the fact that we have accelerated movement towards medical intervention instead of therapy first to borrow, to borrow the name there. So what is the difference? And you even said looming that medical intervention is looming over, which could cause some parents faster gut reaction to be to almost put up their defenses, I think is maybe what you said or something along those lines.

Ryan Vet · So what do you think? First of all, what is the conversation here between medical and therapy first? And, you know, what are some of those next steps that parents should immediately have with their kids instead of just jumping to in many parents' mindsets, you know, they jump to the worst case scenario that the parent doesn't want. And parents do that anyway.

Ryan Vet · Parents always think of you know the worst possible outcome based on their perspective or their experiences. And that's I think a natural reaction as a parent, but not always the healthiest reaction as a parent. So what are some of those conversations that you have with the families to that even predate the first time that they walk across your door?

Paul Garcia-Ryan · Well, I'll start by just going back to the evolution that this field has been experiencing. I think you are aware that Europe has really moved back to a therapy-first approach for youth. And I say moved back because this area of healthcare started in a way that really just focused on therapy for youth, for minors. And then it shifted into medical interventions, puberty blockers, feminizing and masculinizing hormones, surgeries.

Paul Garcia-Ryan · And as it shifted, there have been ways in which therapists have been working in such a way where they seem to be only affirming and not actually doing real in-depth psychological work. That is helping a young person move through their own process and move through their development to reach developmental milestones and to ensure that any co-occurring mental health issues are addressed and treated. And this is now often happening in North America since Europe has moved back to prioritizing mental health care and psychotherapy for youth, and restricted and limited the use of medical interventions for minors.

30:09 A health care issue caught in a culture war

Paul Garcia-Ryan · But America, North America, the US, and Canada remain outliers. And, you know, as you know, it's, you know, you said that you put this conversation through a polarization meter and it came up really high. It's become ensnared in a culture war and become so political, a high-stakes health care issue that is affecting the most vulnerable among us has become a football in a political football in a culture war.

Paul Garcia-Ryan · I mean, how does that happen? It and it has really led to this population continuing to receive subpar care, particularly in the mental health field. There are many clinicians who are very intimidated to work with these young people for a whole host of reasons related to this issue being so white hot in our culture. I think there's actually a lot more agreement amongst therapists than disagreement.

31:46 Where people agree, and the misconceptions

Ryan Vet · I think, and I pulled some statistics up and have them here. Do Americans agree? And I think you're exactly right. Almost every single marker, more than 50% of at least both parties agree on most of these issues. And so I think a big one that you could look at is looking at use for minors, considered anyone under 18 from the legal definition.

Ryan Vet · It says average of 63% of Americans agree, according to the New York Times, with 54% of that being Democrats agree that no blockers or hormones should be given to minors, and 90% of Republicans, which probably isn't a surprising statistic there, shouldn't be given. But there are loud voices on either side. And it, as you have said, with any issue, that I think you said it so well that this issue has become a political football and it's impacting the most vulnerable.

Ryan Vet · And I want to unpack the most vulnerable here because not only are we talking about youth, but we're talking about youth, and you've said it several times in our conversation that usually have a coexisting mental health concern that is that they're also having to navigate through and walk through. And so it's not just this one concern or this one diagnosis of gender dysphoria. There's usually something else, and we're now using them to get a political agenda pushed on one side or another.

Ryan Vet · And that's sad and that's scary. And I think you know, you were quoted in a New York Times piece a couple years ago, written by Pamela Paul, and you talked about your own experience when you were 15, and you said you were immediately affirmed. And that was the exact quote, and that there was no therapy for you. And I think that is definitely something that has fueled where you stand today.

Ryan Vet · But what are some of the big misconceptions? Because I think both sides, and I know we're using sides probably more liberally than we should, but it is a polarizing issue. I think everyone involved in this conversation has misconceptions on both gender dysphoria and transgenderism. What are some of those big misconceptions you're seeing from either from any political camp, from any angle?

Ryan Vet · What are some of those things that we need to just air out here?

34:03 What "affirm" actually means

Paul Garcia-Ryan · Well, I'll start with one that is related to what you just gave voice to about my own care, the care that I received when I was a young person. So one of the misconceptions is that is that the word is that therapists who are using the term affirm that when they use that term they mean that they are comfortable with greenlighting or facilitating a medical intervention, or that they are practicing therapy in such a way that is confirming a young person's current state of current experience of gender and identity.

Paul Garcia-Ryan · That is the real concern amongst many clinicians who are worried about how the mental health field is going about this issue with young people, is that therapists are not offering the neutral exploration and neutral process that therapy ought to offer a young person. And that instead what's happening is that they're affirming only with a young person when it comes to their experience of gender dysphoria and their experience of their identity development in a way that in the sense of the definition, the dictionary definition of affirm, which is to agree with, to say, yes, that's who you are, that's who you always will be, it's never gonna change, which is which has serious implications in an area of healthcare that could lead to medical interventions that have lifelong implications and implications for your health.

Paul Garcia-Ryan · And it essentially is a therapist who is seen as an authority figure by the young person, someone who knows more than they do, basically tampering with that young person's identity development process.

Paul Garcia-Ryan · Every therapist working with a young person experiencing gender dysphoria ought to hold a young person's gender identity with an open palm, like a Buddhist. You know, the Buddhists are always talking about, you know, you want to hold things with an open palm. You don't want to you don't want to hold it like, you know, in a way that is too tight. You want to be flexible, you want to have and, you know, maintain a space where that process can unfold in a way that ensures that process is not being foreclosed for that young person.

Paul Garcia-Ryan · But a lot of but that one of the things that has become an issue in the field is that, like I said earlier, terms are always changing and evolving in this area, and the meaning of terms is always changing. And the word affirm was never meant to be synonymous with a medical model, but it's now become so controversial because it has been tied to a medical model.

Paul Garcia-Ryan · But your average therapist doesn't actually know that. They're still operating from the old definition. I mean, Ryan, I could call up a hundred therapists right now and ask them, are you an affirming therapist?

38:57 Same words, different definitions

Paul Garcia-Ryan · And 90% of them would say yes. And if I were to ask those therapists if they're comfortable greenlighting a medical intervention for a minor experiencing gender dysphoria, 80% of them would say no. And so this whole notion that there are affirming therapists over here and non-affirming therapists over here, you know, the good guys over here who, you know how to work with young people and are, you know, really the responsible ones and, you know, don't affirm.

Paul Garcia-Ryan · And the ones over here who say that they're affirming and they're actually irresponsible. Well, that is just not the case. And the care that I received was the care that was affirming in the dictionary definition of affirming meaning to agree with. Yes, that's who you are. If you go into the dictionary and you look up the word affirm, there's another definition which is to offer emotional support and encouragement.

Paul Garcia-Ryan · And that's what most therapists think of when they hear that word. You know, so that is a misconception that I think is important to address. And it's one of the things that makes finding common ground something that is enormously important to prioritize right now in the mental health field, very difficult because therapists are talking past one another, using the same words, but hearing different meaning and hearing different definitions with those words.

Paul Garcia-Ryan · When it comes to other misconceptions, well, there are a couple.

41:34 Gender dysphoria is not the same as trans identity

Paul Garcia-Ryan · I think one is that gender dysphoria is not synonymous with trans identity. Many have come to think of the two as synonymous. I think because in our current culture so often diagnostic labels are being identified with. People are identifying with diagnostic diagnoses. But the two are not synonymous. They're not the same. If a young person's gender dysphoria resolves, and that young person decides not to pursue medical transition, it doesn't mean that they'll stop identifying as trans.

Paul Garcia-Ryan · That is something that is important for therapists to understand. I think another misconception is that I don't think well, I don't think that many therapists have considered that gender dysphoria can resolve without medical intervention. And also, I don't think that they've considered that gender identity is can be fluid and actually is fluid, especially when it comes to youth. And there are also youth who identify as trans, who do not meet diagnostic criteria for gender dysphoria, but who get the diagnosis by therapists of gender dysphoria, and then get greenlit for medical interventions solely because they identify as trans.

Paul Garcia-Ryan · And so then that raises the question what is it that we're treating as therapists, but also as healthcare professionals, all healthcare professionals who are working in this area.

43:53 Whose scope is it?

Paul Garcia-Ryan · I was speaking with some colleagues this week about how I don't see greenlighting medical interventions as being within the scope of the therapist. I didn't receive any medical training. I went to grad school for two years to study social work and psychotherapy. I was trained in how to work with thoughts and feelings, how to work with diagnoses that are in the DSM to work with the mind, to work with the psyche.

Paul Garcia-Ryan · I was not trained on how to determine whether someone would benefit from a medical intervention like hormones or surgeries. And a colleague of mine said, Well, you know, and he's an endocrinologist, and he said, Well, I was trained that since I'm not a mental health professional, I can't diagnose and know if this person really has gender dysphoria. So what I'm really doing is carrying out the medical treatment of the mental health professional who's giving the mental health diagnosis, which is then treated through hormones.

Paul Garcia-Ryan · And he essentially was saying he the conversation got to a place where he essentially said that because he's not a mental health professional, he is, you know, he needs to rely on the mental health professional. And then I got thinking, well, because he said that he was trained that the job, his role was to carry out the treatment, the medical treatment of the mental health professional, I got thinking to myself, well, the med the medical treatment, the treatment that a mental health professional provides is psychotherapy.

Paul Garcia-Ryan · With psychiatrists, it's psychotropic medication. The medical treatment that an endocrinologist carries out is endocrine-based treatments for endocrine disorders. And so he and I got to this place where we were like, oh.

Paul Garcia-Ryan · So the way it's been going is actually out of the scope for both of us. It's out of the scope for me as a therapist to be facilitating or to be greenlighting a hormone intervention or any medical intervention for my patient. But it's also out of his scope to be treating a diagnosis that is in the DSM, which is the Diagnostic Statistical Manual of Mental Disorders.

Paul Garcia-Ryan · So the whole field, this area is really broken all around. And to get back to what you said about the most, you know, about what we said about the most vulnerable, it's not just young people, it's also trans people, trans adults who are receiving care in this system, which is a system that is providing both youth experiencing gender dysphoria and adults who transition with shoddy health care, subpar health care.

48:53 Labels, fear, and hard conversations

Ryan Vet · That's really profound. And I think you've hit on so many interesting things. One of the things I remember I was a psych minor, so you know, real experience. Yeah. But one of the things was there was a diagnosing unit and we would use the DSM, just and this is like psych 101. And a lot of those things, whether it's depression or anxiety, have actually pretty high thresholds.

Ryan Vet · You have to check multiple boxes. It's not just I'm sad today or this experience makes me nervous. It's usually chronic, it's usually multiple symptoms or signs. And you said something so profound, and I say it a lot in my writing. We have subscribed to almost this label economy where sometimes these labels are even proudly worn, whether it is you know, proudly expressing something like gender dysphoria or transgender or neurodivergence or anxiety or any of these, we wear it around.

Ryan Vet · And part of it might be in my very unclinical diagnosis and some of those a coping mechanism, or you know, if I put it out there, then it can't come back and get me. But I think you've hit on so many important things. And I think this is a conversation that I know you continue to have through events and through your own work with the nonprofit Therapy First.

Ryan Vet · And I think there's so many layers to this conversation that need to be had because people don't want to talk about it because it's for many, it's uncomfortable, or it's foreign, or they're afraid that if you say the wrong thing, or if I misgender someone in this conversation, or I use the and I'm guilty of it growing up in Chicago, use guys, you know, we say guys all the time.

Ryan Vet · It we get so fearful that we can't have a conversation to understand what's really going on out there. So with a last few minutes, I would love for you to do two things. Just briefly, if you could summarize what your hope for the future is in this conversation, and then second, how can people find more about you and Therapy First?

51:03 Hope for the field, and where to find Therapy First

Paul Garcia-Ryan · Well, what I hope is that this issue in the mental health field in particular becomes one where therapists are more likely or more able to work together. And for therapists to feel comfortable to come together and grapple with the questions that this particular moment in time raise for their work with youth. How are young people developing and experiencing themselves in the 21st century? And what does that mean for the therapists who care for them?

Paul Garcia-Ryan · We can be found at therapyfirst.org. We do a lot of training and professional development, both online and also in person. We're going to be hosting in October a first of its kind conference in New York City that is for the first time bringing together high-caliber clinicians of diverse perspectives to try and find the common ground that is really urgently needed in this area of the mental health field.

Paul Garcia-Ryan · And we really hope that any therapist who is listening to this or anyone who knows therapists, you know, we hope that they'll join us. It's an all hands-on-deck moment for the mental health profession. And we especially need leaders in the field to step up and be part of this moment.

Ryan Vet · Well, Paul, I appreciate that so much. And I so often say, you know, we have more information at our fingertips, and you could even argue that information is knowledge, but so often that information and knowledge lacks the wisdom and experience. And I think your perspective is so profound because of your experiences as a child, as a teenager into your 20s, and now helping others walking through the same thing you walk through.

Ryan Vet · I think that's valuable. And I appreciate you diving into issues that are not easy to talk about, sharing your own experiences in that and being willing to just have the hard conversations because you care about the next generation. So, Paul, I really appreciate you and thank you for your time.

Paul Garcia-Ryan · Oh, well, thank you so much. Thank you, Ryan.

Ryan Vet · And everyone, thanks for tuning into this episode of The Ryan Vet Show. Inspire forward.

Ryan Vet · Thanks for tuning in to The Ryan Vet Show. Be sure to subscribe, comment, and…

Full show notes

Paul Garcia-Ryan identified as a woman from age 15 to age 30, then chose to detransition. Today he is a licensed clinical social worker and the president of Therapy First, and he argues that the debate over gender and young people has a lot less to do with sides than the culture war makes it look.

Paul joins Ryan Vet to share his story in his own words: an early childhood sense that he was different, his medical, social, and legal transition, and his training as a psychotherapist at a leading gender clinic in New York City. He explains what changed once younger patients began arriving in his own practice, and how that led him to rethink gender dysphoria and his own history.

Paul now works with young people and their families, and with trans adults, and leads Therapy First, a nonprofit focused on raising the standard of care in youth mental health. He and Ryan talk about how the field has shifted from a mental health model toward a medical model, why therapists often talk past each other because they use the same terms with different definitions, and how a generation raised on algorithms and social media forms its identity differently than the one before it.

For parents, Paul’s advice is to stay curious about what your child is experiencing, however frightening it feels, and to avoid locking horns, because a family in conflict is a family under strain. For clinicians, he describes therapy first as the established standard of care, and says every therapist should hold a young person’s identity with an open palm. His closing call: this is an all-hands-on-deck moment for the mental health profession, and it needs leaders to step up.

This episode reflects one person’s lived experience and professional views. It is not medical or mental health advice. If you or someone you love needs support, please reach out to a licensed professional.

IN THIS EPISODE

Paul’s personal story, in his own words, and why he decided to detransition
What he saw in his practice when the young people arriving at gender clinics changed
How the field moved from a mental health model toward a medical model
Why therapists talk past each other, and why he says there is an illusion of sides
How algorithms and social media shape identity formation in adolescence
What he tells parents: stay curious, and avoid locking horns with your child
What therapy first means as a standard of care, and why leaders in the field need to step up

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Website: therapyfirst.org

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Paul Garcia-Ryan: Why Therapists Disagree Less Than You Think on Gender and Youth Mental Health