Podcast Summary: The Protocol – Episode: The American Approach
Introduction
The Protocol, a six-part podcast series by The New York Times, delves into the evolution of medical treatment for transgender youth in the United States. The episode titled "The American Approach", released on June 5, 2025, explores the origins of transgender healthcare, the transformative impact on young lives, and the ensuing legal and political battles that threaten its future.
Early Insights from Amsterdam
Laura Edwards Leeper, an influential clinical psychologist, recounts her initial exposure to transgender healthcare protocols in Amsterdam. In 2007, shortly after the Dutch introduced their pioneering protocol, Laura spent a week observing the Amsterdam clinic.
"I was just sitting there like, you know, wide eyed, like, okay, trying to soak it all in as much as I could." (00:41)
Under the mentorship of Anna Lou, Laura witnessed the meticulous psychiatric assessments and case discussions that formed the foundation of the Dutch approach. She noted the stringent criteria before initiating hormone treatments, which emphasized a heavy mental health component.
Adapting the Dutch Protocol to the U.S.
Upon returning to Boston, Laura faced the challenge of adapting the Dutch model to the American healthcare landscape. Limited resources contrasted sharply with the Netherlands' comprehensive team.
"Yeah, I absolutely could not replicate it because first of all, they had a lot of mental health people, you know, and one endocrinologist... there was no possible way that I was going to be able to." (01:40)
To address logistical constraints, Laura developed a structured clinical interview, condensing what the Dutch conducted over months into a single session. This adaptation aimed to streamline assessments for patients traveling from across the expansive United States.
Rising Demand and Shifting Patient Demographics
By the early 2010s, transgender youth programs expanded across major U.S. children’s hospitals. Laura observed a significant surge in demand, mirroring trends in Canada and Europe. This increase was partly attributed to heightened visibility and internet connectivity, facilitating greater self-awareness among youth.
"I think the Internet is a huge piece of it... getting answers much sooner than they would have otherwise." (13:12)
Additionally, the demographic profile of patients evolved, with a notable rise in female-born and non-binary youth seeking care. These patients often presented more complex mental health profiles, including higher incidences of anxiety, depression, ADHD, and autism.
Evolving Clinical Approaches: Gatekeeping vs. Gender Affirming Model
As more clinics emerged, a divergence in treatment philosophies became apparent. Initially, the Dutch model's emphasis on thorough mental health assessments contrasted with the burgeoning gender-affirming model in the U.S., which prioritized allowing youth to lead their gender identity exploration without extensive gatekeeping.
At a pivotal 2015 gender conference, Laura experienced a heated debate over assessment protocols. A fellow panelist criticized the necessity of rigorous assessments, sparking a standing ovation from the audience for this dissenting view.
"They wanted meaning to just listen to the kid and help explain to the parents..." (15:33)
Joanna Olson Kennedy’s Alternative Perspective
Joanna Olson Kennedy, a medical doctor at Children's Hospital Los Angeles since the early '90s, was instrumental in challenging the Dutch-influenced gatekeeping approach. She advocated for a more immediate, trust-based model, arguing that prolonged assessments could delay essential interventions.
"We knew that people going through their endogenous puberty left them with changes that they would never be able to walk back." (21:54)
Joanna questioned the efficacy of intelligence testing and other restrictive measures employed by the Dutch, emphasizing the need for flexibility in therapeutic relationships and assessments.
Legislative Backlash and Public Debate
The shift towards a gender-affirming model coincided with increasing political opposition, particularly in conservative states. In 2021, Laura and Joanna co-authored an essay in The Washington Post titled "Mental Health Establishment is Failing Trans Kids," critiquing what they termed "sloppy, dangerous care." The article accused healthcare providers of undermining standards of care and silencing detransitioners.
"We need to be problem solving... we have to be talking about it, and we have to be coming up with a solution to move forward in a better direction." (37:08)
This publication came amidst a legislative surge in 2022 and 2023, with over 100 bills introduced aiming to restrict or ban gender-affirming care for minors. The political climate intensified fears within the medical community about the repercussions of voicing concerns.
Media Exposure and Professional Consequences
Following the controversial Atlantic article in 2018, which spotlighted detransitioners, Laura became a vocal advocate against the rapid medicalization of transgender youth. Her subsequent essay in the Washington Post further solidified her stance but also led to repercussions within professional circles. The American branch of WPATH (World Professional Association for Transgender Health) temporarily restricted its members from speaking to the press, and Erica Anderson, co-author of the essay, resigned from her leadership position.
"If my child was going through this... I would feel like, what the hell is going on here?" (37:15)
Current Tensions and Future Outlook
Laura continues to voice concerns about the hastened transition processes, fearing an impending backlash as more individuals question the validity and safety of current treatment protocols. She urges transparency and collaborative problem-solving to navigate the complex landscape of transgender youth healthcare.
"It was reminding me that as I read that, that I had no clue how huge this was going to be and absolutely no clue." (09:30)
As legislative efforts intensify and public opinion remains divided, the medical community stands at a crossroads, balancing the urgent needs of transgender youth with the complexities of providing safe, informed, and compassionate care.
Conclusion
The American Approach episode of The Protocol highlights the intricate and evolving dynamics of transgender youth healthcare in the United States. Through the experiences and insights of key figures like Laura Edwards Leeper and Joanna Olson Kennedy, the podcast underscores the challenges of adapting international protocols to diverse domestic contexts, the tensions between different treatment philosophies, and the broader societal and political forces shaping the future of gender-affirming care.