A Middle Ground in Pediatric Gender Medicine?

Last month, the New York Times published a podcast series called The Protocol, which asks how science and politics in youth gender medicine got “so entangled.” In a previous essay, I explained why Times reporter Azeen Ghorayshi and her audio producer, Austin Mitchell, offered a disappointing account of the politics of pediatric gender medicine in the United States. The podcast series, I wrote, gave the “unmistakable” impression that there is a right way to do pediatric gender medicine—the “assessment model,” which some believe differentiates between kids who “really need” medical interventions and kids who don’t—and a wrong way, the child-led “gender-affirming” model that came to dominate American clinics.

I may have overstated things when I said this impression was “unmistakable.” After listening to feedback, I learned that some listeners came away from the podcast thinking that even the assessment model was problematic. Nevertheless, The Protocol reflects a growing belief within elite liberalism that while gender medicine did go off the rails, it needn’t have done so. If only mental-health professionals were more involved in the process to determine who really is a “good candidate” for gender transition, the thinking goes, this area of medicine would have operated according to scientific and ethical standards and faced less political blowback.

Maybe. But to assume that an assessment model to pediatric transition is appropriate simply because it sits between the “extremes” of age-minimum laws (“bans”) on the one hand and a child-led “affirming” approach on the other, is to commit what I’ve called the “golden mean fallacy.” To give an obvious example of why this thinking is fallacious: Jim Crow sits between the extremes of chattel slavery and racial equality, but no reasonable person would defend it on that basis.

Given that puberty blockers and cross-sex hormones are invasive and often irreversible treatments offered to physically healthy children ostensibly for a mental-health condition (gender dysphoria), advocates of the assessment approach must have good answers to several key questions.

Is there a plausible clinical rationale for the treatment? What are doctors treating—gender dysphoria, gender incongruence, or transgender identity? If gender dysphoria, does the diagnosis, as described in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders have enough diagnostic specificity? What do we know about this condition’s causes and natural history in different populations? Is the goal of treatment the alleviation of gender dysphoria or realization of “embodiment goals”? More fundamentally, do gender medicine’s core concepts—sex, gender, gender identity, and transgender—have scientifically valid definitions? If not, what does that suggest about the integrity of the field as a whole?

Is there evidence to support the Dutch approach? Does it matter that the two Dutch studies—which documented the initial results of early medical intervention in children with gender dysphoria—are flawed? Does it matter that two efforts to replicate the studies both failed? Does it matter that a central justification for the Dutch approach—that puberty blockers are “fully reversible” and part of the diagnostic process—is no longer credible and has been abandoned by leading gender clinicians? Does it matter that research on medical harm has been sparse, potentially creating the misimpression, through “publication bias,” that such harms don’t exist?

What is the ethical justification for the Dutch approach? Given the known and expected health risks of early intervention, is it ethical to offer these treatments outside of well-controlled research settings? Is it ethical to offer them within such settings? Are young adolescents capable of providing informed consent? Are rates of regret and satisfaction, even were they known, appropriate proxies for determining the ethics of pubertal suppression and hormone therapy? Given the overrepresentation of gay and autistic youth in the gender dysphoric population, are there unexamined considerations of justice?

Any journalistic coverage of pediatric gender medicine that wishes to avoid the golden mean fallacy must explore these questions in depth. Unfortunately, the Times podcast all but ignores them. It freely uses terms like “trans kids,” as if the meaning of that phrase were obvious. It refers to “gender identity,” as if that term hadn’t been subjected to (largely unanswered) academic criticism for reflecting circular reasoning and a reliance on stereotypes. It reductively equates patients’ satisfaction with medical beneficence and regret with medical malfeasance and contains not a single interview with a bioethicist or other expert who can shed light on the thorny ethical issues involved in uncontrolled experimentation on vulnerable minors. And though it very briefly mentions some of the problems with the Dutch studies, it fails to reflect on the significance of those issues for the field as a whole.

Rather than complain more about these issues, I decided it might be beneficial to interview Laura Edwards-Leeper, a clinical psychologist whom the Times podcast presents—at least in my view—as a stand-in for pediatric gender medicine “done right.” Edwards-Leeper doesn’t see it that way and was surprised to hear that I did. But it’s hard not to notice the podcast’s negative attitude toward “bans,” on the one hand, and its skepticism toward the child-led “affirming” approach, on the other. The Times suggests that the logical alternative to these options is the model developed in the Netherlands and brought to the U.S. by Edwards-Leeper and her colleague, endocrinologist Norman Spack. Notably, Ghorayshi and Mitchell did not subject Edwards-Leeper’s claims to even a fraction of the scrutiny they gave St. Louis whistleblower Jamie Reed, who spent four years working at a pediatric gender clinic and has since become one of the field’s most outspoken critics.

Edwards-Leeper is a controversial figure within gender medicine and among critics of the discipline. Many of her colleagues regard her as a dangerous heretic who helped fuel a backlash to medically necessary and life-saving care. Her critics accuse her of importing a new form of gay conversion therapy in progressive disguise—an accusation she vehemently rejects—and of offering services driven by ideological beliefs.

I’ve known Edwards-Leeper for a while, and though we disagree strongly on key issues, I’ve always found her to be someone who is friendly, who genuinely wants to help her patients, and who exhibits a generosity that is sometimes lacking in her critics. Edwards-Leeper agreed to grant me an interview, which is presented below and edited for length and clarity. To her credit, she grappled candidly with some of the most difficult questions facing the field. I encourage readers to consider how her answers respond to the three issues I’ve outlined above—clinical rationale, evidence, and ethics—and to decide for themselves whether and to what extent her approach is a reasonable path forward for gender medicine.

Leor Sapir: I want to start with your impression of the New York Times’s podcast, The Protocol. You feature in it as someone who helped bring pediatric medical transition to the United States and who offers a more cautious, assessment-based approach than the one that took root here. We’ll discuss your approach in a minute, but first, is there anything you think the creators of the podcast, Azeen Ghorayshi and Austin Mitchell, got wrong? Anything they should have done differently?

Laura Edwards-Leeper: I’m generally happy with the podcast, but I was disappointed by the lack of discussion around detransitioners. I believe Ghorayshi had intended to include a significant part about that, and I don’t know what happened, but it leaves the listener missing a very important part of the whole controversy. It would have been helpful and more balanced to hear perspectives both from people who found their transition helpful and from those who had regret or experienced negative outcomes.

Sapir: As you know, part of the debate over youth gender medicine—indeed, perhaps the most important part of that debate—concerns the foundational concepts in the field: transgender, sex, gender, and gender identity. What do you make of The Protocol’s repeated use of the term “trans kids,” or some variation thereof? Some believe this is a neutral, descriptive term, but others say it’s ideologically loaded and puts a thumb on the scale in favor of medicalization. What’s your view?

Edwards-Leeper: I agree that it’s not a neutral term. These days, I worry that calling gender-distressed young children “trans” puts them on a more likely path toward medicalization, a path that can be very hard for some to get off. I do wish the podcast had done a better job on this front. I used to use “trans kid,” but try not to do so anymore, partly because it could skew clinical reasoning and partly because I’ve seen too many kids (and adults in their lives) assume that if the child identifies as trans at one point in time, they will always be trans. I feel strongly that we should do everything we can to prevent kids from feeling boxed into a particular identity or trajectory.

Sapir: Is sex binary? Is it assigned at birth?

Edwards-Leeper: The reality of biological sex should not be ignored in gender medicine. However, intersex conditions suggest that sex isn’t binary. And yes, doctors typically assign sex at birth.

Sapir: What about gender identity? I’m guessing you’re aware of the criticisms of the term, which suggest that it relies on circular reasoning or sex stereotypes. How do you understand it?

Edwards-Leeper: Gender and gender identity are social constructs, and that’s why it’s hard to have clarity around the term. I agree that it involves stereotypes. From my perspective, it’s how someone identifies themselves, coming from both their internal sense of who they are and how that feeling fits within the gendered world in which we live. There are obviously people who don’t identify with their biological sex. Even if gender identity is a social construct that involves stereotypes, the inability to express oneself in the way that feels most comfortable and authentic can cause considerable distress. In some cases, that distress is significant enough that it would be harmful not to support that person’s gender identity, particularly if nothing else has alleviated the distress. Neither of us has gender dysphoria, so neither of us knows what it’s like to have that experience. What makes all this more complicated is that these days, the construct of gender identity has become something broader, something that young people are being told that they can choose. Additionally, experiencing dysphoria is no longer considered an essential component for transitioning in some people’s opinions. This is a very different way of understanding gender identity and dysphoria than it was [understood] ten to 20 years ago.

Sapir: The Protocol mentions that the “gender-affirming” model, represented in the podcast by Johanna Olson-Kennedy, has become the dominant one in U.S. health-care settings. I’ve heard you talk about this before and I’m not sure people understand just how dominant it’s become. What can you add here?

Edwards-Leeper: Based on my clinical experience, the large majority of the pediatric-gender-medicine field in the U.S. uses the child-led approach, but I don’t claim to know what I can’t see. Maybe more providers than I’m aware of are offering a more formal, thorough, and developmentally informed process. I’ve spoken with and heard about parents and patients who are satisfied with the care they’ve received—including on the podcast. So, I just don’t know. It does feel like, from my perspective, that there’s been a massive shift toward limiting assessment and seeing it as unnecessary. Olson-Kennedy’s approach is probably at the extreme of the non-assessment approach, and there’s probably a lot between her approach and mine.

Sapir: Just to clarify, you feel that providers may be doing more assessments than your clinical experience would suggest because there are patients and parents who say they are happy with the care they’ve received? Meaning, you infer that they got thorough assessments because they say they’re satisfied. Right?

Edwards-Leeper: Yeah. And I often ask them specifically what the process they went through entailed. I also know of some colleagues who report doing a more thorough assessment process.

Sapir: What exactly is your clinical approach nowadays? You mentioned on the podcast that you don’t do “gatekeeping” anymore. But the podcast does refer to your approach as “the assessment model,” and some listeners might take this to mean that you say “yes” or “no” to kids who wish to transition based on some independent criteria. Can you explain?

Edwards-Leeper: Because of how dominant the child-led model has become, the devaluing and lack of understanding by some medical providers regarding the assessment process, and the ease with which motivated adolescents and their parents can get hormones, my approach has been pragmatic. I don’t do gatekeeping in the way I was expected to do when I started my career in this field, and I don’t claim to be able to predict which child will go on to have a lifelong transgender identity. What I do is provide a holistic assessment of the adolescent’s gender-related history, exploration of other aspects of their identity (e.g., sexual orientation, race, religion), social and family relationships, academic history, and most importantly, a comprehensive mental health assessment. Additionally, I spend considerable time assessing the young person’s expectations for the medical intervention they are seeking, to assess how much they know and how realistic their expectations are. I also spend many hours with the parents to hear their perspectives, obtain background information on their child, and discuss their concerns. My goal is to help the child and parents have as much information as possible so that they can truly give informed consent if they decide to proceed with medical interventions.

These days (in many states still), it is ultimately up to the parents and child to decide how to proceed, as it seems rare that medical clinics will refuse medical interventions to a young person who wants them. My assessment typically takes ten or more hours, over the course of several sessions and results in a 20–30-page report. I don’t write short “letters” of support [typically required for gender transition procedures] because I feel that is completely insufficient, irresponsible, and unethical. The report offers significantly more information than what the clinics are requesting these days, so my hope is that with that information, families will be able to make the best decision for their child.

Given the complexity seen in most of my cases these days, many times, my recommendation is to slow things down and encourage the young person to take more time to address complicating factors, treat mental-health conditions, and explore what might be causing the adolescent to feel gender dysphoric and want hormones. Unlike some of my “blindly gender-affirming” colleagues, I recognize that these days, kids sometimes identify as transgender for any number of reasons, including social pressures or unmanaged mental-health conditions. Unfortunately, doctors in this space rarely value the work of mental-health professionals like me. I feel that they sometimes look down on us, maybe because of the American medical hierarchy, which places mental-health providers below medical providers. So, at this point in time, my report is mainly for the adolescent and their parents, if they wish to rely on it.

Sapir: So, if you see a kid whose trans identity seems to stem from online influence or some underlying distress, do you tell the parents that he or she isn’t a good candidate for medical interventions?

Edwards-Leeper: Not necessarily. What I do is tell the parents and the adolescent that these other factors might have influenced their child’s sense of gender, and that, based on my experience, kids who do well after medical intervention are different from their son or daughter. In these cases, I would encourage the adolescent to dig into this potential influence more so that they could sort out what was true for them.

Sapir: In your amicus brief with Erica Anderson for U.S. v. Skrmetti [the recent Supreme Court case assessing the constitutionality of Tennessee’s ban on hormone therapy as a treatment for pediatric gender dysphoria] you wrote that medical transition is “potentially ‘life saving’… for some adolescents,” but the data do not support this claim. The best available evidence (from Finland) suggests that comorbid mental health conditions, not gender dysphoria per se, explain the elevated risk for suicide (which is still very low). Can you explain?

Edwards-Leeper: We were very careful with our language here because in our clinical experience, we have deemed medical care to be lifesaving for some adolescents, but not all. I feel this argument is too often used to strong-arm parents (by adolescents and some health-care providers) to proceed with medical interventions in cases when it is not appropriate. At the same time, to say that it does not appear to be lifesaving in some circumstances when one’s dysphoria is severe and other treatments have been exhausted and ineffective, would be lying. That was the point we were trying to make. The Finnish research is consistent with my clinical experience for the majority of adolescents, particularly in the last decade or so.

Sapir: The problem, as I see it, is that clinical opinion, on which you rely here, is at the bottom of the pyramid of evidence in evidence-based medicine, and for good reason. Unsystematic observation cannot yield credible insights about cause and effect. We have to rely on the best available evidence, which doesn’t support the claim that gender transition is “life-saving”—though it also doesn’t definitively disprove that claim.

Edwards-Leeper: I’m not sure it is possible to design a research study to address the suicide question in the way you feel we could arrive at the answers you’re looking for. For that reason, we need to incorporate the existing research with our clinical expertise to determine the best treatment plan for each individual patient. The “trans youth and suicide” topic is not as black-and-white as I think many people (on both sides of the argument) would like to believe it is.

Sapir: A major problem in the U.S. seems to be the gender clinic model of care. In the U.K., the central gender clinic was well-established as a psychotherapy center before it started approving kids for hormones. But in the U.S., pediatric gender clinics were established only after the medical pathway [the practice of treating trans-identifying kids with hormones and surgeries] was created, and arguably in order to provide medical interventions. The very existence of specialized gender clinics, one could argue, biases clinical decision-making in favor of medical interventions. Is that how you see it?

Edwards-Leeper: Yes. From my experience, once a kid enters these clinics, their fate is all but sealed. The clinics rarely say “no” to kids who want hormones. The Dutch did comprehensive assessments by at least two mental-health providers before the patient ever saw a hormone-prescribing doctor. One assessment was more therapy-focused and ongoing over the course of months or years, and the second was a more structured, second opinion. I tried to set up a model in Boston that approximated this by relying on community mental-health providers. This was initially successful, but as the demand grew and the mental-health field was unable to keep up, it became impossible to offer such a comprehensive process for each patient seeking care. Mental-health providers wanted to help with the demand, but I believe some started offering services even if they did not have sufficient training in child/adolescent development and gender identity development. Additionally, there was a change in the clinical population [most did not have childhood dysphoria and struggled with complex mental health conditions]. In many respects, a perfect storm developed for the field to become completely overwhelmed by both patient numbers and complex patient presentations.

Sapir: Some argue that your approach, though seemingly more conservative, is at least as problematic because the kids whom you regard as “true trans” and whom you believe—perhaps in accordance with the Dutch Protocol—are good candidates for hormone therapy, are, in many or most cases, gay. There is growing concern that “gender-affirming care” is a progressive version of gay conversion therapy—turning gay kids “straight.” Almost all of the 70 kids in the Dutch study were same-sex attracted. Other studies have shown very high rates of same-sex attraction among trans-identified kids, and the Dutch clinicians themselves said that gender dysphoria is more predictive of homosexuality than later transsexuality. There are some indications that F.G., the first Dutch patient to receive hormones who was interviewed by the Times, was attracted to other females and had a father who disapproved of masculinity in girls. Some detransitioners say, “I’m gay and I just needed people to help me accept that,” and some gay adults say, “If I were a kid these days, I might have gotten swept into this as well.” What do you say to such concerns?

Edwards-Leeper: First, I don’t use the term “true trans,” and I certainly never pretend that I can predict with 100 percent certainty who will persist in their trans identity and who won’t, or who will definitely benefit from medical interventions and who won’t. I don’t have a crystal ball, and we don’t have a blood test or brain scan to shed light on this question. Regarding the topic of gay conversion therapy, I am frustrated that this has become such a focus among gender-critical people. While confusion around one’s sexual orientation and how that relates to one’s gender identity, along with internalized homophobia, is absolutely one important area to explore through assessment and therapy, it is certainly not the only—or even most important—complicating factor to consider, based on my clinical experience. Among desisters [children whose gender dysphoria resolves over time without medical intervention] and detransitioners I’ve worked with, not all are gay. Research does show a strong correlation between early childhood gender nonconformity and later gay or lesbian sexual orientation, so I always inform the parents of my young clients (and the adolescent clients who were gender nonconforming in childhood) that this is a very possible path for their child. However, many of the gender-questioning teens I work with were never gender nonconforming in childhood, and their sexual attraction is all over the map.

Regarding the Dutch study, I don’t think anyone in the field sees it as you’re describing it. If you’re describing sexuality strictly based on physical bodies and chromosomes, then yes, a majority were homosexual. If we’re going to be super specific with language, I think the term “same-sex attracted” is easier to understand, because to me, that relays that you’re talking about biology and not the term someone might use describe their identity in terms of sexual orientation. So, if you’re talking about how the person lives their life and self-identifies in terms of their gender and sexual orientation, I don’t think it’s accurate to say most are gay—same-sex attracted, yes; gay, no.

I remember a couple clients I had back in Boston who had very religious parents and relayed the message to their child that they would go to hell if they identified as gay. As a result, these young people were terrified of being gay, so identifying as transgender felt safer. But these days, homophobia seems very different. Some youth and parents tell me that it’s cooler to be trans than to be gay today, so that needs to be sorted out as well. But when we’re talking about the Dutch cohort, I don’t think those patients were trying to be cool. Perhaps some felt it was better to be trans than to be gay, but in most cases, people find that living as a trans person is much more difficult than being gay, so I think that reason for transitioning was probably unlikely for most. It would be interesting to ask the early Dutch patients if they’re happy with their current sexual orientation and whether they feel they could have been just as happy living with the body with which they had been born.

I have some concerns when working with young people who have had no sexual experiences or relationships, who maybe identify as asexual, and who want to transition. To make such a big decision that involves altering your body before exploring and becoming more clear about your sexuality seems very risky to me.

I also find it interesting that a significant number of the moms of the patients I work with tell me that they were tomboys as kids and many felt a lot of distress when going through puberty. Some of them even say that they may have chosen to transition if it were an option when they were younger, but as they matured, they became more comfortable as women.

Sapir: What do you tell kids or their parents when giving them information about medical interventions?

Edwards-Leeper: Well, we spend a lot of time covering this in the assessment process. But in a nutshell, I discuss what the hormones will and won’t likely do (also emphasizing that this needs to be discussed with a medical provider as well, as I am not a hormone prescriber). I review all of their complicating issues and share any concerns I have about specific risks for them if they move forward. If there are complicating factors at play, I strongly encourage them to address those first and then reconsider whether a medical path is still best for them. Sometimes, they will return to me for a follow-up assessment, and sometimes they will ask to continue working with me to address the concerns raised by engaging in therapy with me.

Sapir: Do you tell them about the systematic reviews and their finding that there is no reliable research to support the claims about the mental-health benefits?

Edwards-Leeper: I don’t say it that specifically, I guess, but that’s largely because, since the Cass Review [Britain’s report on the treatment of gender-dysphoric children] came out, most parents who are considering medical interventions for their child come to me after having already read it, plus a lot more. If they haven’t, I encourage them to do so. I have always told patients (way before the Cass Review was published) that there is almost no research on the long-term outcomes of trans youth. I share the limitations of the Dutch study and emphasize that one of the biggest risks in pursuing medical interventions is that there is a lot we don’t know. I tell them that they are guinea pigs and they have to decide if they are okay with that. It’s also important to note that my caseload is self-selective. Almost all the parents who reach out to me indicate that they are looking for a more balanced approach—one that is neither blindly affirming nor unwilling to affirm. Many of these parents are somewhat skeptical, but most say they will support their kid transitioning if it is determined that doing so will likely benefit them. They all are seeking a more thorough process, something they assumed would be the standard protocol but were dismayed to learn isn’t the case.

Sapir: I want to conclude with a question about schools. This issue isn’t really explored in the Times podcast. Let’s start with elementary schools. Is it appropriate for schools to introduce kids at this age to transgender identity, ask kids to share pronouns, and have materials in the hallways depicting transgender identity in a positive light?

Edwards-Leeper: This isn’t happening everywhere, thank goodness, but it’s happening in some places and I feel it is absolutely ridiculous. It infuriates me that some elementary schools are approaching this in the way they are. It’s so vastly different than it was when I got into this work. Back then, the parents would lead the way—they’d approach the school with requests and a plan; they were the advocates for their child. But now, the schools often assume that all parents of gender distressed youth are the “bad guys.” So instead of parents taking the lead for their child, the schools have decided to take the lead and often leave parents in the dark. This creates more tension and conflict in the family and often results in children not getting the help they need.

I also can’t believe what’s happening with teachers, or other adults who go into the schools to provide education about “gender identities” to children, who have no background in child development or gender identity development. These adults are confusing kids who otherwise would never have questioned their gender. I’m not suggesting we should prevent kids from being trans who will ultimately benefit from transitioning, but I’ve had clients tell me what’s going on in their schools and I feel strongly that it is causing confusion among so many kids. In my opinion, if there’s a child in class who’s made a social transition, the class can be made aware of it, and there should be no bullying, but that should be the end of story. Elementary schools should not make it standard protocol to have all children share their pronouns.

Sapir: What about middle schools? They often use instructional materials like AMAZE videos, which teach that some kids are trans or nonbinary. Is that appropriate?

Edwards-Leeper: I’d have to see the exact material, and I should say that I believe education around gender and sexuality can be done in a developmentally appropriate way, even for younger kids. But the way that it’s framed is critical. If it’s described as a menu of options, a la carte, where kids are encouraged to check off an identity, based on gender stereotypes, that is clearly problematic. If taking puberty blockers and hormones is presented as an easy option for any child who feels uncomfortable with puberty and/or doesn’t like the gendered expectations placed on them, I feel that the school is contributing to confusion which could ultimately lead to physical and psychological harm of their students. I do believe that most schools are approaching this topic in the way they feel is most compassionate and helpful, but I believe they have been led astray by messages and information that are not evidenced-based or developmentally informed.

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