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.
Chapter 1: What did Laura Edwards-Lieper learn in Amsterdam?
When you went, how long were you in Amsterdam and what did you see while you were there? I was only there for about a week. So it wasn't like a tremendous amount of time. But I sat in with Analu doing several assessments, like psychiatric assessments. And I sat in with the team, you know, while they discussed cases because they would thoroughly discuss every single case before they did anything.
And the team was,
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.
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.
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.
The Dutch were very, very strict with who they allowed to start hormones. And so I remember talking to Ana Lu 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 U.S., like when I came back to Boston.
So you were adapting their approach, right? You couldn't replicate their approach.
Right. 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. Yeah.
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Chapter 2: How did Laura adapt the Dutch approach in the U.S.?
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.
Their assessment process, they did kind of over the course of a year or more, I think.
In the Netherlands, most people lived within driving distance of the clinic and could come for regular visits. But in the U.S.,
People were going 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.
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.
And so basically what I created was a structured clinical interview.
So what the Dutch had done across many months, Laura packed into a single session on a single day.
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 these various psychological measures or 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.
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Chapter 3: What challenges did Laura face in her role?
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 and 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.
There's just so much new here. Like, 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?
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 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 Europe by myself for a while. Yeah.
But it was reminding me that, as I read that, that I had no clue how huge this was going to be. Absolutely no clue.
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.
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 couldn't live any other way. Like, 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 incredibly helpful it was to so many of these kids, it really confirmed for me that it was the right intervention.
In 2011, Laura and her family moved to the Pacific Northwest. That same year, Analu published her landmark Puberty Blockers paper.
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Chapter 4: How did the demand for gender clinics change over time?
In Laura's mind, the surge in demand also had to do with the new ways kids were connecting and accessing information online.
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 sometimes getting answers much sooner than they would have otherwise.
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.
Aside from that, you know, the big things were the later onset of gender dysphoria with no childhood, you know, gender confusion.
There were more kids who had first expressed feelings of gender dysphoria in their teenage years as opposed to early childhood.
And... Much, much more complex mental health presentations.
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.
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Chapter 5: What factors contributed to the increase in gender dysphoria cases?
That it can never be because someone experienced a traumatic experience. 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.
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.
Laura talked about a conference in 2015. You were both on a panel.
Between Laura and the doctor who had gone after her approach.
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, not the specific event. I'm just thinking about getting a standing ovation because I don't remember that at all.
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.
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.
And it was this way of thinking that was starting to take hold in the U.S.
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Chapter 6: What differences did Laura notice in patients at her clinic?
That's right.
That's right. When you started incorporating puberty blockers into your treatment here in L.A., were you following that protocol that they had introduced over there?
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 what's going to be on the other end of that.
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.
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.
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.
One of the things that the Dutch repeatedly did was intelligence testing. And so they published IQ tests. 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.
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Chapter 7: How has the approach to treating gender dysphoria evolved?
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 healthcare matters, right?
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. Joe Olson says children are born this way.
Joe began to talk publicly about her approach.
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. And what does support look like? It's different for each kid.
And she also began speaking about something else.
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Chapter 8: What was the significance of the 2015 conference for Laura?
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.
That was one of the most difficult experiences I've ever had in the field.
And Laura realized just how dominant Joe's approach was becoming, and just how out of favor her approach now was.
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. 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. I
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