Laura Edwards-Lieper

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.

Between Laura and the doctor who had gone after her approach.

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.

And it was this way of thinking that was starting to take hold in the U.S.

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.

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.

While Jo immediately understood the transformational power of this new intervention, she wasn't as convinced as Laura 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.

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.

To Jo, 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.

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.

And often, she said, the kid was also talking to a therapist while they were going through this process. But Jo didn't think it had to be mandatory or for a set period of time.

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.

Joe began to talk publicly about her approach.

And she also began speaking about something else.

She started to talk about this care in life or death terms.

Joe wasn't alone in this either. As visibility around trans kids was growing in the US, 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.

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.

From The New York Times, I'm Austin Mitchell. This is The Protocol with Azeen Gureshi. Part 3. The American Approach.

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 U.S. Just a few weeks after that, she appeared at that conference with Laura.

And Laura realized just how dominant Joe's approach was becoming, and just how out of favor her approach now was.

In 2018, The Atlantic published what would turn out to be a highly controversial article about youth gender medicine in the U.S. 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.

Laura 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. Joe 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.

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.

Laura said she had received emails from many health care providers privately telling her that they agreed with her.

but they were afraid to speak publicly about their concerns.

When Laura started at the new gender clinic at Boston Children's Hospital, known as GEMS, she was excited.

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.

This was when political opposition was intensifying in red states around the country. In the months before Lara 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.

But she had never really worked with kids who had gender dysphoria before.

In 2022, more bills targeting gender-affirming care for young people were introduced in state houses 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, another person from the medical world did speak out. 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.

That's next time in Part 4.

At this point, there weren't really any mental health providers in the U.S. 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.

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 U.S., 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.

Laura Edwards-Lieper 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.

In the Netherlands, most people lived within driving distance of the clinic and could come for regular visits. But in the U.S.,

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.

So what the Dutch had done across many months, Laura packed into a single session on a single day.

So almost as soon as she started, Laura decided to make another adjustment to the protocol.

She had just been hired as a part-time clinical psychologist for the very first youth gender clinic in the U.S., and she had been sent there to learn their process.

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.

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.

In 2011, Laura and her family moved to the Pacific Northwest. That same year, Analu published her landmark Puberty Blockers paper.

Laura was consulting with doctors and hospitals across the country.

She was also teaching her approach to clinical psychology grad students.

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.

What Laura was seeing wasn't just happening in Portland. Around the U.S., 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.

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 cover of Vanity Fair, Laverne Cox on Orange is the New Black. Time magazine called this moment the trans tipping point.

In Laura's mind, the surge in demand also had to do with the new ways kids were connecting and accessing information online.

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.

There were more kids who had first expressed feelings of gender dysphoria in their teenage years as opposed to early childhood.

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 U.S. to meet the demands of this new group of patients.

the thinking over how best to treat them was changing too.

She was seeing providers moving away from extensive mental health assessments and toward an approach that put much more emphasis on what the kids said they wanted.

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.

She was one of four panelists discussing age limits for hormone treatments in front of an audience of other clinicians.