← The Protocol
The Protocol
The American Approach
00:41:08
In Boston, a psychologist helps set up the first youth gender clinic in the U.S., adapting the Dutch approach. Across the country, a rising star in the field questions their methods. Meanwhile, demand increases worldwide as the types of patients seeking care change.
Loading summary
Transcript150 lines
- [00:01]
Interviewer
What did you see when you went, how long were you in Amsterdam and what did you see while you were there?
- [00:07]
Laura Edwards Leeper
I was only there for about a week, so it wasn't like a tremendous amount of time. But I sat in with Anna Lou doing several assessments, like psychiatric assessments. And I sat in with the team while they discussed cases because they would thoroughly discuss every single case before they did anything. And, and the team was.
- [00:29]
Austin Mitchell
Lara Edwards Leeper first visited the Amsterdam clinic back in 2007, shortly after the Dutch published the first outline of their protocol. And word of this new treatment had started to spread overseas.
- [00:42]
Laura Edwards Leeper
You know, I was just sitting there like, you know, wide eyed, like, okay, trying to soak it all in as much as I could.
- [00:47]
Austin Mitchell
But she had just been hired as a part time clinical psychologist for the very first youth gender clinic in the US and she had been sent there to learn their process.
- [00:57]
Laura Edwards Leeper
They were very, the Dutch were very, very strict with who they allowed to start hormones. And so I remember talking to Anna Lou after some of the assessments that I sat in on and asking, you know, why she wasn't like approving hormones for this kid. Where from what I could tell, the mental health issues were really directly tied to the gender dysphoria. And it seemed like that would really help. But they, you know, were just following a very, very strict protocol and that's really, that's what helped me figure out what to do back in the US like when I came back to Boston.
- [01:32]
Interviewer
So you were there was, you were adapting their approach, right? You couldn't replicate their approach?
- [01:40]
Laura Edwards Leeper
Yeah, I absolutely could not replicate it because first of all, they had a lot of mental health people, you know, and one endocrinologist, you know, it was like just very, very heavy mental health component. And I was one person with like four hours a week devoted to this. Like, so, you know, there was no possible way that I was going to be able to. Yeah.
- [02:04]
Interviewer
Do you worry about that first jump from the sort of way the Dutch were doing things to how things kind of evolved here?
- [02:14]
Laura Edwards Leeper
Yeah. Yes, I do. I mean, and I, I actually was thinking about this the other day, how they were so generous. You know, they took me under their wing, they taught me the ropes and then trusted me, you know, trusted me to bring this to our country and try to make it work. And there is a part of me that definitely feels like I've let them down in some way. It's weird, I mean, cause obviously I know I'm not, I can't be that response. I'm not responsible for all of this, you know, going wrong. But I think that they know, I hope that they know how hard I've tried to keep things on the right track.
- [03:02]
Austin Mitchell
From the New York Times, I'm Austin Mitchell. This is the protocol with Azine Qureshi. Part three, the American Approach.
- [03:21]
Laura Edwards Leeper
So I got my first job at Boston Children's Hospital, actually in the primary care center there. And while I was working in primary care, the gender program was getting started. And so I saw an email saying that they needed a very part time psychologist and like responded immediately.
- [03:42]
Austin Mitchell
You know, when Laura started at the new gender clinic at Boston Children's Hospital, known as gems, she was excited.
- [03:49]
Laura Edwards Leeper
Always. I've been always very interested in like gender development and specifically I was really interested in adolescent girls and their.
- [03:58]
Austin Mitchell
But she had never really worked with kids who had gender dysphoria before because they're just.
- [04:02]
Laura Edwards Leeper
That was not talked about at that time. That wasn't an area of focus at this point.
- [04:06]
Austin Mitchell
There weren't really any mental health providers in the US who had experience working with these kids the way the Dutch did. The dominant approach was behavioral. So kids would often end up seeing psychologists who were focused on steering them toward their birth sex.
- [04:22]
Laura Edwards Leeper
You just need to take away all of the boys toys and encourage them, you know, to do the girl things and then they'll be fine being a girl, you know.
- [04:31]
Austin Mitchell
But this new clinic in Boston was going to be different because one of the founders had been following what the Dutch were doing with puberty blockers and wanted to offer that care in the US which is why he'd sent Laura to the Netherlands to learn the Dutch process. And when she got back and started to adapt it, there was one change she knew she would have to make right away.
- [04:54]
Laura Edwards Leeper
Their assessment process. They did kind of over the course of a year or more, I think.
- [04:59]
Austin Mitchell
In the Netherlands, most people lived within driving distance of the clinic and could come for regular visits. But in the US people were going.
- [05:08]
Laura Edwards Leeper
To be coming from all over the country. So obviously they weren't going to be able to meet with me, you know, for therapy, you know, over every week.
- [05:15]
Austin Mitchell
Kids would have to travel to Boston from all over the country. So it wasn't going to be possible to have multiple sessions over the course of a year.
- [05:23]
Laura Edwards Leeper
And so basically what I created was a structured clinical interview.
- [05:30]
Austin Mitchell
So what the Dutch had done across many months, Lara packed into a single session on a single day.
- [05:38]
Laura Edwards Leeper
Lots of questions about gender, identity development, what's going on in the family, significant events in the kid's life. You know, of course Asking about, like abuse and trauma and all of that kind of stuff was an important piece. And then in addition to the clinical interview, then I've used, you know, these various psychological measures or, you know, questionnaires that ask questions about mental health as well as gender related things. And then I would do a feedback session where I would verbally go over all of the results and information. And so, yeah.
- [06:21]
Interviewer
Four hours a week just seems impossible to do the job that you were just describing. I mean, how long were the assessments?
- [06:27]
Laura Edwards Leeper
Yeah, so I mean, basically what it, what it ended up looking like was I think I did like one to two assessments a month. Oh, wow.
- [06:37]
Interviewer
So it was that there were that few patients that. Yeah, yeah.
- [06:41]
Laura Edwards Leeper
But what occurred to me after one or two of those assessments was that it was just me making the decision. Someone who was very new to this field and only one person. Where the Dutch had two people, like at least two people, like making. Weighing in a year over the course of a year. So I felt very overwhelmed by the responsibility that was on me to be a gatekeeper. Cause really I was expected to be a gatekeeper at that point. These days we never say that, and I don't really think of it that way, but at the time I was absolutely expected to be a gatekeeper.
- [07:17]
Interviewer
So you're stamping yes or no?
- [07:19]
Laura Edwards Leeper
Yes. Yeah, exactly. And so I guess I was nervous about, you know, just being responsible for making a decision that would lead to a person, you know, a young person changing their body permanently. I mean, that just seemed like a really huge responsibility.
- [07:39]
Austin Mitchell
So almost as soon as she started, Laura decided to make another adjustment to the protocol.
- [07:44]
Laura Edwards Leeper
We were going to require the young person to be in therapy with someone who was going to work with them longer term.
- [07:53]
Austin Mitchell
She decided that kids had to see a mental health provider on their own for at least eight months before they could have their appointment with her in Boston.
- [08:01]
Laura Edwards Leeper
We wanted them to be with somebody, like established relationship with a therapist long enough that the therapist could weigh in and know them well and know them well. And also so that therapist could stay with them through the course of, like, if they did start hormones and they would have someone to support them. The problem though, for the first several years was getting those mental health people to agree to be a part of it because no one knew anything about this work. And so, you know, I spent time, you know, sort of being a cheerleader on the phone with people around the mental health people around the country telling them, like, what kinds of things to do to provide support and how to, you know, ask Questions to just engage in therapy with the kid and basically just help alleviate the therapist's anxiety around being involved. You know, I felt like I didn't know a whole lot, but they knew even less. But it did feel good just to know that there was at least another mental health person who was weighing in. And I felt like I was more closely following the Dutch.
- [09:06]
Interviewer
There's just so much new here. Like, I really listening to you right now, it seems like, do you ever look back and think, like, did I not, Did I even know what I was doing? But like, just that nothing. There was no infrastructure for this care in the United States. Were you ever just nervous about doing it at all?
- [09:30]
Laura Edwards Leeper
You know, it's funny, I was trying to find some of my old notes and I couldn't find anything other than like, my, like, personal journal where I unfortunately did not write a whole lot about what I was doing. Work wise. It was more just like my life at that time and being over in the, you know, you know, Europe by myself for a while. But, but 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.
- [10:04]
Austin Mitchell
I mean, in the first four years at the clinic, Laura saw just 70 or so patients and passed nearly all of them on for puberty blockers or hormones.
- [10:14]
Laura Edwards Leeper
It was pretty rare that I said no. I mean, at the beginning when the cases were straightforward, just the fact that the young person was surviving in the world as a trans person when everything was going against them, but yet they, they couldn't live any other way like they, they. Their dysphoria was so severe that once we treated them medically, their mental health did improve drastically. And I remember giving talks about how many kids were able to stop taking their psych meds after they started transitioning, because it really, you know, it was clearly tied to that. So when I saw how like, incredibly helpful it was to so many of these kids, it really confirmed for me that it was the right intervention.
- [11:06]
Austin Mitchell
In 2011, Laura and her family moved to the Pacific Northwest. That same year, Ana Lou published her landmark puberty blockers paper.
- [11:15]
Laura Edwards Leeper
And then it just kept growing.
- [11:17]
Austin Mitchell
Laura was consulting with doctors and hospitals across the country.
- [11:21]
Laura Edwards Leeper
There was just a growing need to train psychologists and other mental health providers on the assessment especially, but meant just the therapy too.
- [11:30]
Austin Mitchell
She was also teaching her approach to clinical psychology.
- [11:33]
Laura Edwards Leeper
Grad students felt like I was starting to make a dent in getting my field up to speed.
- [11:39]
Austin Mitchell
Youth gender programs were opening at major children's hospitals in Chicago, Cincinnati, San Francisco and Los Angeles. And then around 2014, 2015, while Laura was working with a new clinic in Portland, she noticed a lot more kids were showing up for care.
- [11:58]
Laura Edwards Leeper
And it was just filling up like crazy.
- [12:04]
Austin Mitchell
What Laura was seeing wasn't just happening in Portland. Around the us In Canada and across Europe, clinics were reporting a surge in demand. One of the biggest recorded increases was in England, where referrals went from 200 in 2011 to 1,400 in 2015.
- [12:23]
Laura Edwards Leeper
I think, you know, in terms of the time frame, you know, people often ask, well, why did the numbers increase at that point? And the most common response you get from a lot of people is, well, it was talked about more and so the acceptance. Right. And so people felt more comfortable coming out.
- [12:37]
Austin Mitchell
Most clinicians agree that part of what was contributing to the increase in demand was growing advocacy and awareness of trans identity. It was. Caitlyn Jenner on the COVID of Vanity Fair. Laverne Cox on Orange is the New Black. Time magazine called this moment the trans.
- [12:54]
Laura Edwards Leeper
Tipping point, which I think absolutely explains part of it, but that there is no way that explains all of it. Absolutely no way, from my perspective that that explains all of it. I, I think the Internet is a huge piece of it, because when I started this work, none of these kids weren't. There was no social media. Like, there was no.
- [13:13]
Austin Mitchell
In Laura's mind, the surge in demand also had to do with the new ways kids were connecting and accessing information online.
- [13:20]
Laura Edwards Leeper
And so I think that's been a huge thing that has shifted. That has led to an increased number of young people questioning their gender and, and sometimes, you know, getting answers much sooner than they would have otherwise.
- [13:35]
Austin Mitchell
You know, but it wasn't just that clinics were seeing a lot more patients. They were also reporting that the kinds of patients coming in were starting to change too. There were far more kids who were born female. In a lot of clinics, it was twice as many. Whereas before, there had been slightly more kids who were born male. There were also more kids identifying as non binary, so not as trans boys or trans girls, but more fluid or in between.
- [14:04]
Laura Edwards Leeper
But aside from that, you know, the big things were the later onset of gender dysphoria with no childhood, you know, gender confusion.
- [14:15]
Austin Mitchell
There were more kids who had first expressed feelings of gender dysphoria in their teenage years as opposed to early childhood.
- [14:22]
Laura Edwards Leeper
And much, much more complex mental health presentations.
- [14:27]
Austin Mitchell
There were kids who had more complicated psychological profiles with higher rates of conditions like anxiety, depression, adhd. There were also even more kids with autism compared to years before. It was a new group of patients that often didn't fit the profile of the kids the Dutch studied. They weren't like FG or Manon. And Laura said she started to notice that as more and more clinics were opening in the US to meet the demands of this new group of patients.
- [14:59]
Interviewer
So what did you start to see over time as more of these clinics opened up? What was your sense of how they were approaching things?
- [15:09]
Laura Edwards Leeper
It definitely shifted.
- [15:12]
Austin Mitchell
The thinking over how best to treat them was changing too.
- [15:15]
Laura Edwards Leeper
To follow the kids lead and to be supportive and to affirm and to help get the parents on board.
- [15:25]
Austin Mitchell
She was seeing providers moving away from extensive mental health assessments and toward an approach that put much more emphasis on what the kid said.
- [15:34]
Laura Edwards Leeper
They wanted meaning to just listen to the kid and help explain to the parents what the kid is saying and then help facilitate the connection with a medical clinic.
- [15:44]
Austin Mitchell
But from Laura's telling, she didn't fully understand just how much the field was changing until she was invited to speak at a gender conference in 2015.
- [15:54]
Laura Edwards Leeper
It was an annual conference, and I'd gone there every year, like I'd been invited.
- [15:58]
Austin Mitchell
She was one of four panelists discussing age limits for hormone treatments in front of an audience of other clinicians.
- [16:05]
Laura Edwards Leeper
Part of what I was asked to talk about was like, the assessment process and why. What. What it entailed and why it was important. And it turned into this very tense conversation about assessment being like this hurdle that people were being made to jump through. And one of the other panelists just felt very strongly that it was completely unnecessary. And she even said retraumatizing to people to have to tell their story a second time or if they'd already told it when they came out to their parents. That alone was shocking, that there was this perspective that the mental health role was causing trauma to the patients that we were trying to help. But then I think what was even more shocking was the reaction from the audience, which was a standing ovation for the person who was commenting about assessment so negatively. People just were suddenly seeming to feel like it needed to be like child led entirely, and that there could never be complicating factors that needed to be looked at, that it can never be because someone experienced a traumatic event or they're just fed up with what's expected for them as an assigned female. And so they wanted to escape that. That the gender piece was always just in and of itself a separate thing that we needed to treat as quickly as possible, whereas that's never been the way I've seen it.
- [17:53]
Austin Mitchell
We spoke with one of the other providers on the panel and the conference organizer. They both said the discussion was tense and that it really became a two person debate.
- [18:03]
Interviewer
Laura talked about a conference in 2015. You were both on a panel between.
- [18:07]
Austin Mitchell
Laura and the doctor who had gone after her approach.
- [18:11]
Interviewer
She also said you got a standing ovation. Does that track with. Do you have a similar memory of how this happened, this played out? I remember that.
- [18:22]
Joanna Olson Kennedy
Not the specific event. I'm just thinking about getting a standing ovation because I don't remember that at all.
- [18:31]
Austin Mitchell
As it turned out, this doctor had also been watching what the Dutch were doing back when word of their protocol was spreading around the world. But she thought about it very differently.
- [18:41]
Joanna Olson Kennedy
Year long assessment or six month assessment. I think that we started recognizing in some cases that's doing more harm than good, especially when you're talking about a puberty timeline.
- [18:53]
Austin Mitchell
And it was this way of thinking that was starting to take hold in.
- [18:57]
Joanna Olson Kennedy
The US what happens if you require someone to be in therapy for a year, but they have no interest in that? That doesn't make sense.
- [19:21]
Interviewer
So, Joe, Dr. Joe Olson Kennedy, do you pronounce your name Johanna or Joanna?
- [19:27]
Austin Mitchell
Johanna with the H. Dr. Joe Olson Kennedy joined the faculty at Children's Hospital Los Angeles back in 2006 in the Division of Adolescent and Young Adult Medicine.
- [19:38]
Interviewer
So can you tell me about your own work here? When did you actually start providing this care?
- [19:45]
Joanna Olson Kennedy
So I do not think of myself as a single individual. I want to go back in history and talk about really this work arising from HIV care. And so we had an HIV youth program before we started doing gender care. And that included a population of older adolescents and young adult trans women, many trans young women of color. And so when these young people were coming in for HIV related services, either prevention, testing or treatment, they were beginning to ask, hey, can you do our hormone related care here? And so it's not widely publicized, but we began within the division to do that care in the early 90s.
- [20:35]
Austin Mitchell
So when Jo came in, the clinic was already working with some older trans teens. But then right around the time she started, the Dutch published their outline for using puberty blockers. The same one that inspired GEMS to send Laura to the Netherlands right after it was published.
- [20:52]
Joanna Olson Kennedy
I don't remember the exact details surrounding that because it's been a long time, but it made sense. And it was right off the bat, brilliant. I mean, it made complete sense. We knew that people going through their endogenous puberty left them with changes that they would never be able to walk back. And that was especially considering the population. Right. That we're working with. We knew that historically it's identifiable trans women of color that are the targets and the victims of violence and sometimes homicide. And so if we could create a situation whereby they were not identifiable, that's life saving. It was like a piece that clicked into place. And in fact, I remember saying, this is so obvious, it's kind of astonishing that somebody didn't talk about this or think of this earlier.
- [21:54]
Interviewer
Intuitively made so much sense to you that you didn't have to wait till 2011 or whenever they published their first batch of data on these kids.
- [22:04]
Joanna Olson Kennedy
That's right. That's right.
- [22:13]
Interviewer
When you started incorporating puberty blockers into your treatment here in la, were you following that protocol that they had introduced over there?
- [22:24]
Joanna Olson Kennedy
So the idea, I think what they did was what they needed to do. Like any area of medicine, when you're first starting something or introducing a new mechanism for caring for people, you probably err on the conservative side, not knowing, like, what's going to be on the other end of that.
- [22:46]
Austin Mitchell
While Joe immediately understood the transformational power of this new intervention, she wasn't as convinced as Lara about the rigorous assessment process the Dutch were doing, in part because when she started prescribing puberty blockers around 2007, the kids who were coming in looking for help weren't really young kids like many of the kids the Dutch were seeing. Some had already started their natal puberty or were just about to.
- [23:14]
Joanna Olson Kennedy
If you truly want to use puberty blockers to block puberty, you can't do a year of assessment when they come in right around the time of puberty. You have to do that in concert with that intervention.
- [23:26]
Austin Mitchell
The way Jo saw it, these patients were up against a clock. Delaying the treatment defeated the purpose of the intervention. But she also had some deeper issues with the assessments the Dutch did.
- [23:38]
Joanna Olson Kennedy
One of the things that the Dutch repeatedly did was intelligence testing. And so they published IQ tests. Yeah, right. And so do we need to do intelligence testing? I don't really. There was never really a compelling reason to do that, given that they had done this over and over again and found that the intelligence was the same as the population at large. So what other things were they doing around therapy, especially if they were excluding people with mental health issues? So I'm not sure. I don't know that there's ever been information published about what were you doing in those therapy sessions, besides honestly making yourself feel comfortable about the gender that the young person is asserting can you.
- [24:26]
Interviewer
Talk about that a little more? Like, do you think. Is that what you. Do you think assessment is sort of. It's clearly trying to get a sense of greater certainty about how a kid will identify in the future. You're laughing, so I want to hear what your thoughts are about that.
- [24:50]
Joanna Olson Kennedy
I hope that if they figured that out, they would publish that, because I have never for any certainty had or read a publication about. Here are the things that tell us. If somebody's going to continue to assert this gender over time, who are you assessing now that in 30 years did not assert the same identity? Who is that and how did your assessment help you with that? I think that's a really important question to Joe.
- [25:24]
Austin Mitchell
It was unrealistic to think that mental health providers could somehow predict the outcome for these kids decades down the line. And she said even trying to predict it was going to affect their relationship with their patients.
- [25:37]
Joanna Olson Kennedy
If somebody is in the role of an assessor and they're supposed to also be creating a therapeutic alliance with somebody, those things are at odds with each other. And there actually has been.
- [25:51]
Interviewer
That sets them up as a gatekeeper.
- [25:53]
Joanna Olson Kennedy
Well, I mean, being the person that checks a box that says you can move forward with medical interventions. I think there have been some data, and I don't know exact. I can't quote the exact article right now, but that has demonstrated that if people know they're sitting with someone, that's going to either check off the box or not. If you're worried that you're going to disclose something about your life that then is going to keep you from getting what you deserve and need, you're unlikely to disclose that information. And that's a problem. You don't want that.
- [26:29]
Austin Mitchell
And so as Jo began to meet with patients, she said she felt comfortable as a medical doctor doing her own assessing of the care they might need.
- [26:37]
Joanna Olson Kennedy
I mean, every patient in medicine gets assessed.
- [26:41]
Austin Mitchell
And often, she said the kid was also talking to a therapist while they were going through this process. But Joe didn't think it had to be mandatory or for a set period of time.
- [26:51]
Joanna Olson Kennedy
There are huge benefits to mental health therapy, but I don't think you just can say, like, each person needs exactly this amount of therapy. Like, that's not how humans are. I think that if there was evidence that demonstrated a year of assessment changed the outcome for young people, then I would have been like, oh, okay, that makes sense. But there really hasn't been that.
- [27:19]
Interviewer
But it was also the only data that we had at that point. Right. The Dutch by 2011. That was the only data. That was the only data we had.
- [27:29]
Joanna Olson Kennedy
We'd been doing the care since 1991. So yes, there's published data, but there's also experience in the field. And experience in the field is what we have when data is being collected. Our experience matters. Experience in health care matters.
- [27:49]
Austin Mitchell
The way Joe was thinking about assessment reflected a broader push that was underway against so called gatekeeping in trans medicine for adults. For years, patients and advocates had been challenging the prominent role of psychotherapy and were finally getting doctors to ease some of the requirements for treatment, including the need for patients to get a letter of approval from a therapist before starting hormones. They argued that these requirements showed an ongoing mistrust of trans people and of patients own understanding of who they were and what they needed. Joe was among a growing group of providers who were making a similar case for kids. That the strict requirements of the Dutch protocol were outdated and perpetuated that mistrust and that children should be believed when they say what their gender is. Not long after she started seeing patients, Dr. Jo Olson says children are born this way. Jo began to talk publicly about her approach.
- [28:55]
Joanna Olson Kennedy
It's a different process for each child. Young people and their families come in in very different stages of this process. It's really important just to support your kid. Now what is support look like? It's different for each kid.
- [29:08]
Austin Mitchell
And she also began speaking about something else.
- [29:11]
Joanna Olson Kennedy
We often will ask parents, you know, would you rather have a dead son than an alive daughter?
- [29:17]
Austin Mitchell
She started to talk about this care in life or death terms.
- [29:21]
Joanna Olson Kennedy
To me it seems ridiculous to have.
- [29:23]
Laura Edwards Leeper
A kid at age 12, 13, 14.
- [29:25]
Austin Mitchell
Deciding whether they want to have biological children when they're 20, 30 or 40.
- [29:30]
Joanna Olson Kennedy
I mean, well, they make the decision to kill themselves at 12 and 13. That's a pretty powerful decision.
- [29:41]
Austin Mitchell
Joe wasn't alone in this either. As visibility around trans kids was growing in the U.S. there was also growing awareness that like trans adults, this was a group at much higher risk of suicidal thoughts and behaviors than the general population. One frequently cited study from the time found that nearly half of the young trans people surveyed had seriously considered dying by suicide. About a quarter of them said they had actually tried to.
- [30:12]
Joanna Olson Kennedy
There are high rates of depression, anxiety, suicide attempts.
- [30:17]
Austin Mitchell
So providers like Joe and parents and kids who had received the care. Would you rather have a happy kid or would you rather have a dead kid? Talked about the urgency of getting kids, what they said they needed. You know, there are some transgender children.
- [30:31]
Laura Edwards Leeper
That have not been able to be transgender who even want to die. Yes. And that's why I'm doing this with you today.
- [30:40]
Austin Mitchell
I want to help those kids become.
- [30:43]
Laura Edwards Leeper
The person they are. And I want to tell the parents.
- [30:47]
Austin Mitchell
That they should still love them no matter what.
- [30:50]
Interviewer
Whenever people ask me, how can I just let her do this? I'd rather have a living transgender daughter than a dead son.
- [31:00]
Austin Mitchell
In speaking out so publicly about this, Joe became one of the most prominent and influential voices in the field, advocating for what came to be known as the gender affirming model of care for kids. It didn't require kids to meet strict criteria for medication. It rejected watchful waiting and set periods of time for therapy or assessment. And the ages kids could start medications shifted too. They no longer had to wait until they turned 12 to start on puberty blockers or 16 for hormones. It was a model that prioritized treating kids on their own timelines. Because the stakes were high. In 2012, as Joe's profile was rising and as demand for care was growing around the country, Children's Hospital Los Angeles officially opened a youth clinic dedicated to gender services. And they made Joe the medical director. A few years later, she got a multi million dollar federal grant to lead the first big study of youth gender medicine in the US Just a few weeks after that, she appeared at that conference with Laura.
- [32:13]
Laura Edwards Leeper
That was one of the most difficult experiences I've ever had in the field.
- [32:18]
Austin Mitchell
And Laura realized just how dominant Joe's approach was becoming and just how out of favor her approach now was.
- [32:25]
Laura Edwards Leeper
When I started to see the field shift, the nightmare that I had was, if things continue to move in this direction that I'm sensing they're moving where assessment's no longer going to be really valued. Young people are going to move more quickly through this process to medicalization.
- [32:45]
Interviewer
And.
- [32:45]
Laura Edwards Leeper
More of them are coming in. The cases are more complex. At the same time, the cases are more complex. We're cutting corners. What's going to happen? Well, probably there's going to be more people who realize it was the wrong decision. And then what's going to happen? Well, probably it's going to result in backlash for after all of these years of work that we have tried to move the society forward with accepting trans people, people are going to start to question it and question, is this even something we should be doing at all, especially with youth? And so I started talking about that. I would tell my students, you know, I probably sounded like a broken record, but I just had this gut feeling that if things did not slow down quickly, we were going to have a nightmare on our Hands. It was because of this that I agreed to be interviewed by Jesse for the Atlantic piece because I couldn't sleep at night.
- [33:41]
Austin Mitchell
In 2018, the Atlantic published what would turn out to be a highly controversial article about youth, gender, medicine in the US and the debate over how best to approach the care. The writer, Jesse Singel, spoke with several people who did feel they had made the wrong decision and had either stopped treatment or reversed the medical transition. It was one of the first high profile stories to focus on a group of people who were coming to be known as detransitioners. In some cases, they talked about feeling rushed into a decision they weren't ready for and getting medical interventions that weren't right for them. Lara was interviewed for the article and she said she believed there would only be more of these stories in the coming years because there were so many kids who weren't getting a comprehensive mental health assessment. Jo was also interviewed and she said that the small number of kids who later regretted their transition shouldn't influence how care was provided to everyone. She said the approach that tries to prevent regret in advance is a, quote, broken model.
- [34:48]
Laura Edwards Leeper
Then the Washington Post piece was the other huge event, I guess, in terms of me speaking out.
- [34:56]
Austin Mitchell
A few years after the Atlantic article, Laura spoke out again, this time more directly and alongside a high profile co author, another clinical psychologist named Erica Anderson. She was the head of the American branch of wpath, the group that set the standards of care in the field. In 2021, they published an essay in the Washington Post called the Mental Health Establishment is Failing Trans Kids. And in it they said that providers were increasingly engaging in, quote, sloppy, dangerous care. They called out doctors by name, including Joe, who they noted prescribed hormones to children as young as 12. They said that in advocating for a model that followed the child's lead and that believed if a child said they were trans, they were. Some doctors had, quote, confessed to ignoring the standards of care. They said, quote, none of this means that we shouldn't be listening to the views of gender diverse teens. It only means that we should listen in the fullest and most probing way possible. And they ended by calling out advocacy organizations and medical providers for what they said was silencing people who expressed regret about transitioning and sabotaging open dialogue in the field. In the aftermath of the Post essay, the American branch of WPATH issued a temporary moratorium on its members speaking to the press, and Erica resigned from her position as the head of the group. Lara said she had received emails from many health care providers privately telling her that they agreed with her.
- [36:39]
Laura Edwards Leeper
I told my husband and my friends, this is it. Like, okay, it's gonna be somebody else's turn to step up to the plate.
- [36:45]
Interviewer
And.
- [36:47]
Laura Edwards Leeper
But it just hasn't happened.
- [36:51]
Austin Mitchell
But they were afraid to speak publicly about their concerns.
- [36:54]
Laura Edwards Leeper
And I guess my perspective is that if I were a parent going through this and no one was talking about it, I would be livid. I would be absolutely livid.
- [37:09]
Interviewer
You mean that doctors and psychologists are having these conversations behind closed doors where they can't access them?
- [37:15]
Laura Edwards Leeper
Right? Yeah. When it was. If my child was going through this and I mean, and then to find out that the providers were being told not to speak about it also, I mean, I would feel like, what the hell is going on here? Like, that is very suspicious. Like, I would be, you know, questioning everything. So I just feel like in order to be transparent with the public and with families going through this, we have to be talking about it, and we have to be coming up with a solution to move forward in a better direction. Like, we need to be problem solving.
- [37:48]
Austin Mitchell
Laura thinks while some of the reluctance to speak up was because of the pressure from groups like wpath, she also thinks some of it was self censorship because something else was happening around this time.
- [38:00]
Interviewer
In terms of your. Your Washington post piece was November 2021. I mean, that year was the first year. That was when Arkansas passed their ban, which was the first ban.
- [38:10]
Austin Mitchell
And then this was when political opposition was intensifying in red states around the country. In the months before Laura published her essay, there was growing momentum for restricting or banning this care for kids, and state lawmakers were citing sloppy care and kids regretting their transitions as part of their justification. So fear was growing in the medical community about the consequences of voicing any questions or concerns.
- [38:39]
Laura Edwards Leeper
The op ed that Erica and I wrote, I mean, we spent, like, I think six months on that, largely, I would say, because we kind of vacillated back and forth about whether we should do it for that very reason. Like, we were worried that it would be used in ways that we didn't want it to be used, and we kind of knew it would be to some extent. And so we knew that that was going to be something we were going to have to deal with. Good will, hopefully come out of it, but there could be some bad that comes out of it, too. And it is very unfortunate that it's been used in ways that we did not want it to be used to support the bands. I'm not in favor of the bans. I really strongly feel like this should be a decision that is made by the family, parents, too, when we're talking about minors and the healthcare providers who are involved. This should not be something that is dictated by, you know, the government. That's crazy.
- [39:48]
Austin Mitchell
In 2022, more bills targeting gender affirming care for young people were introduced in statehouses across the country. And then in 2023, there was a legislative onslaught. Over 100 bills were introduced. And right as legislative sessions were getting underway.
- [40:08]
Laura Edwards Leeper
Whistleblower investigation. This woman claims children are being harmed.
- [40:12]
Austin Mitchell
Another person from the medical world did speak out.
- [40:15]
Laura Edwards Leeper
Jamie Reed worked at the Pediatric Transgender.
- [40:18]
Austin Mitchell
Somebody who had similar concerns to Laura about the way care was being provided. Reid said the center pushed children into puberty blockers and hormone therapies without proper mental health assessment, but who did not share her belief that the government should stay out of it.
- [40:34]
Interviewer
Like, we're on the cusp of this legislative thing and you're, like, diving, like, straight into it. I mean, you're already in it.
- [40:45]
Laura Edwards Leeper
What is the other option?
- [40:48]
Austin Mitchell
That's next time. In part four.
- [40:53]
Laura Edwards Leeper
Sam.