The Assessment Sham
Laura Edwards-Leeper's approach to transitioning minors is as irrational as those she criticizes -- and in some ways more disturbing.
In 2006, an 8th grader told her counselor she felt attracted to girls. The girl figured this made her a lesbian, but she had a hard time saying that word.
She was hardly a unique case. Ellen DeGeneres came out as “gay” in 1997, explaining later that she didn’t like the word “lesbian” because it sounded like a disease. TV’s first sapphic soap opera debuted in 2004. Its title, “The L Word,” was a wink at how loaded that word was. Meanwhile, young lesbians – my peers – embraced a new label, “I don’t believe in labels.”
The heroine of Stone Butch Blues (1993), who takes testosterone to escape butch-dyke persecution but then changes her mind, hesitates to say the word lesbian:
“[I]t sounds too much like lezzie and lesbo. That’s a tough word for me to wrap my tongue around."
A therapist in the UK reported that when he treated ostensibly gay teenage girls in the 2010s:
“I had kids telling me, ‘when I hear the word, lesbian, I cringe. I want to die’ … ‘I’m gonna vomit if I hear the word lesbian another time.’”
The 8th grade girl’s counselor helped her “explore” her discomfort with the word lesbian. And then, eureka. As her mother, Kim, explained on a Massachusetts-based transgender radio show that year, the girl “really didn’t identify as a lesbian, he identified as a boy who liked girls.” That’s why she couldn’t say the L-word.
The girl started school that fall as Shawn. Though Kim did most of the talking on the radio show, Shawn chimed in excitedly to say her social transition was going well; her classmates accepted her as a boy. Kim was trying to track down a doctor who would prescribe testosterone for Shawn, but so far everyone she’d met refused to medicalize kids under 16. Shawn was 14.
Five months after that interview, a clinic opened in Boston with the aim of transitioning kids like Shawn. Its psychologist was Laura Edwards-Leeper.
Since 2017, the media has persistently reported on “detransitioners” who blame their doctors for medicalizing their teenage angst. Edwards-Leeper regularly weighs in to blame the phenomenon on “activist” clinicians who don’t screen patients properly. As she wrote in 2021 with Erica Anderson, “comprehensive assessment and gender-exploratory therapy is the most critical part of the transition process.”
In this post I’ll show you what Edwards-Leeper means by assessment and therapy. And I’ll ask, How would she respond if a homosexual teen girl told her she didn’t identify with the word lesbian?
The Pioneer (2007)
The endocrinology department at Boston Children’s Hospital began evaluating and treating “patients with a broad range of … pubertal stages” with Gender Identity Disorder in 1998.
In February 2007, BCH opened the Gender Management Service (GeMS), which “evolved” out of a program for kids with disorders of sex development. GeMS prescribed puberty blockers to kids who wanted to resemble the opposite sex or to explore their gender.
GeMS’ director was the rough-spoken endocrinologist Norman Spack. The “founding psychologist” of GeMS was Laura Edwards-Leeper.
Edwards-Leeper’s gender accomplishments included a 1997 minor in gender studies at Lewis & Clark College, in Oregon, and a graduate certificate in women’s studies from Bowling Green State University in Ohio, where she also received her PhD in 2004. She visited the Netherlands to learn the new child transition protocol from its inventor, the psychologist Peggy Cohen-Kettenis.
Edwards-Leeper identifies as an “ally to the LGBTQ community,” i.e., straight.
In late 2008, The Atlantic reported on GeMS:
“Spack’s clinic isn’t so comprehensive [compared to Cohen-Kettenis’]. A part-time psychologist, Dr. Laura Edwards-Leeper, conducts four-hour family screenings by appointment. (When I visited during the summer, she was doing only one or two a month.) But often she has to field emergency cases directly with Spack, which sometimes means skipping the screening altogether.
“‘We get these calls from parents who are just frantic,’ she says. ‘They need to get in immediately, because their child is about to hit puberty and is having serious mental-health issues, and we really want to accommodate that. It’s like they’ve been waiting their whole lives for this and they are just desperate, and when they finally get in to see us … it’s like a rebirth.’”
Their feeling of rebirth in the doctor’s office corroborates Sasha Ayad’s observation that transition is like a religious conversion experience.
The Gendered Soul (2012)
In March 2012, Edwards-Leeper and Spack co-authored an article in the Journal of Homosexuality about GeMS. The piece described “the clinic’s protocol … along with treatment philosophy and goals.” In justifying its recommendations to other clinicians, it frequently fell back on the phrase “in our clinical experience …” in lieu of citing formal studies.
The authors use the terms “gender variant” and “gender nonconforming” as synonyms to describe “someone whose interests and behaviors fall outside the cultural norms for biological sex [sic].” These patients are “transgender.” It’s the wide-open definition of transgender that activists advanced in the early 1990s, which doesn’t require a cross-sex identity.
The authors believe “a transgender individual’s gender does not change, as his or her brain (or soul) has always been his or her affirmed gender.” “Gender dysphoria” afflicts some transgender people. It is “a primary physical [sic] rather than psychological condition.” The body is the problem, not the mind/soul.
“a transgender individual’s gender does not change, as his or her brain (or soul) has always been his or her affirmed gender.”
The formal DSM diagnosis in 2012 is gender identity disorder. I’ve written about GID’s “distress fallacy” – a shrink can stick the label on any sex-atypical kid who happens to feel distress about anything. Edwards-Leeper and Spack take the fallacy further. They recommend that clinicians treat the “gender variance” before addressing the other issues:
“[I]n our clinical experience these symptoms [depression and anxiety] in transgender adolescents are often the result of feeling uncomfortable in their body and the social stigma and rejection they experience for being different. … The previous diagnoses of major psychiatric disorders, especially mood disorders (e.g., major depressive disorder, bipolar disorder) in these patients are often secondary to their gender identity issue and many patients are ‘cured’ of these disorders through medical intervention for the gender issue.”
The authors define “sexual orientation” as a “construct, referring to the gender of individuals to whom one is sexually or romantically attracted[.]” This is wrong; sexual orientation is not a construct. It’s biological and based on sex, not gender (a term the authors don’t define, but appear to view as binary).
Not everyone spurns the L word:
“[C]onsider the biological male who affirms a female identity and is attracted to women. This individual would likely identify as lesbian.”
GeMS does not provide therapy. It does require patients to agree to see an outside “mental health care provider,” and to arrive with a “letter of support” from one. The authors do not claim to hold these therapists to any particular standards.
Edwards-Leeper’s role at GeMS is to conduct 4- or 5-hour “comprehensive evaluations” – interviews of new patients and family members. She assesses patients again before each choice about medical interventions (blockers, hormones, mastectomy).
Patients “are unlikely to be denied” blockers by Edwards-Leeper because they’ve already been through GeMS’ “triage system” before meeting her. But “in some instances” she may send them for therapy, for example if their “gender identity has not been consistent or persistent.”
Hormones are prescribed at “approximately” age 16. (The next year, Spack spoke publicly about administering estrogen to 13- and 14-year old boys.)
The authors lead a movement that, through its media blitzes and community outreach, encourages parents to cultivate cross-sex identity in their “gender variant” kids. But they portray themselves as following children’s lead (emphasis added):
“Individuals are … declaring their gender variance at younger ages, forcing those who care for these youth to reexamine the framework from which we understand [GID] …”
Some of their patients do not have a childhood history of “gender variance”:
“Most of these late-adolescent onset transgender patients indicate that they always felt different or knew that something was not right, but were unable to identify it until puberty. Oftentimes these individuals report that they initially thought that their confusion was related to sexual orientation because they were unaware that transgenderism existed.”
This might describe Shawn. The authors continue:
“Most parents of late-onset transgender patients are leery of their adolescent’s newly affirmed gender identity, this is understandable given their child’s lack of history supporting this. However, many of these adolescents report that their friends are not surprised by their declaration of their affirmed gender, often responding that they had suspected it for some time.”
The authors do not suggest these patients should have to attend therapy before medicalizing. Apparently they take seriously the teens’ reports of their friends’ opinions about their gender identity.
Some clinicians hesitate to diagnose autistic kids with GID. The authors turn the tables on them:
“Although the question of whether gender dysphoria is simply a symptom of an autism spectrum disorder has been raised by mental health clinicians in the field, we feel it is equally worth questioning the validity of an autism diagnosis among transgender youth … Perhaps the social awkwardness and lack of peer relationships common among GID-Asperger’s patients is a result of a lifetime of feeling isolated and rejected; and maybe the unusual behavior patterns are simply a coping method for dealing with the anxiety and depression created from living in an ‘alien body,’ as one patient described it.”
The authors do not mention the medical risks and side effects of their interventions.
Guidelines for Inflicting Iatrogenic Harm on Homosexuals (2015)
By 2015, Edwards-Leeper was affiliated with Pacific University in Oregon. She co-authored a manual for the American Psychological Association, “Guidelines for Treating Transgender and Gender Nonconforming People.”
The Guidelines use the term “discordance” to describe unease with one’s own sexuality. These feelings can supposedly be treated through affirmation and medicalization of a trans identity. For example:
“Through increased comfort with their body and gender identity [thanks to affirmation], TGNC people may explore aspects of their sexual orientation that were previously hidden or that felt discordant with their sex assigned at birth.”
If patients feel discordance over their homosexual attraction then shrinks should introduce them to the concept of trans identity:
“To explain any discordance they may experience between their sex assigned at birth, related societal expectations, patterns of sexual and romantic attraction, and/or gender role nonconformity and gender identity, some TGNC people may assume that they must be gay, lesbian, bisexual, or queer. Focusing solely on sexual orientation as the cause for discordance may obscure awareness of a TGNC identity.
“Psychologists may need to provide TGNC people with information about TGNC identities, offering language to describe the discordance and confusion TGNC people may be experiencing. To facilitate TGNC people’s learning, psychologists may introduce some of the narratives written by TGNC people that reflect a range of outcomes and developmental processes in exploring and affirming gender identity. These resources may potentially aid TGNC people in distinguishing between issues of sexual orientation and gender identity and in locating themselves on the gender spectrum.”
This might have happened during Shawn’s counseling sessions back in 2006. She felt discordant about calling herself a lesbian, so the counselor explained she might be male.
If Shawn’s “gender nonconformity” started years earlier (as it does for many pre-gay children), here’s how psychologists should proceed (emphasis added):
“For adolescents who exhibit a long history of gender nonconformity, psychologists may inform parents that the adolescent’s self-affirmed gender identity is most likely stable. The clinical needs of these adolescents may be different than those who are in the initial phases of exploring or questioning their gender identity. Psychologists are encouraged to complete a comprehensive evaluation and ensure the adolescent’s and family’s readiness to progress while also avoiding unnecessary delay for those who are ready to move forward.”
“Serving Transgender Youth” (2016)
In 2016, Edwards-Leeper co-authored an article in a psych journal with Spack and others about how GeMS treated trans-identified kids.
Is therapy required?
“When a child is seeking services closer to puberty, our current model typically recommends three to six months of psychotherapy. For some children who feel a compelling sense of urgency in light of impending physiological changes, this recommendation may be modified[.]”
What’s the point of therapy?
“[P]sychotherapy enables a deeper exploration of the child’s Gender Dysphoria (GD), the range of gender expression and gender identity questioning, and whether the subjective experience fits more into a model of binary identity (e.g., male/female) versus a fluidity of gender and gender nonconformity.”
The authors list “factors that make these cases more complicated” like autism, divorced parents, and history of abuse. Homosexuality and internalized homophobia are not listed.
The authors impose these therapy requirements and wait until “typically around age 16” for cross-sex hormones “to ensure that an adolescent is not ambivalent, and that these interventions are well thought through and understood without coercion from others, and with full consent.”
The authors acknowledge detransition:
“The field needs to better comprehend which children are most likely to have a life-long and persistent identification with a different gender than the one they were assigned versus those who cease to self-identify as transgender over the course of time.”
A lot of autistic kids are turning up with gender dysphoria. After listing reasons why they should not transition, the authors conclude:
“A comprehensive evaluation should help sort through these issues and it may be necessary to move forward cautiously. However, it is our opinion that treatment not be withheld indefinitely as these youth experience the same biological time constraints characteristic of all pubescent individuals, and therefore need to receive optimally timed interventions to the extent possible.”
They say more research is needed on “the effects and side effects of various medical interventions[.]” They don’t list any known side effects. Cross-sex hormones and gender surgery have been used for over 50 years at this point, and the dangers of steroids have been national news for decades.
The authors do list the drawbacks of natural puberty (“intolerable erections”).
Guidelines for Inflicting Iatrogenic Harm on Autistic Adolescents (2016)
That same year, Edwards-Leeper co-authored an article on autistic kids with 22 other gender doctors. They advised:
“Given the increased incidence of gender issues among people diagnosed with [Autism Spectrum Disorder], youth with ASD should also be screened for gender issues. Screening may be accomplished by including a few questions about gender identity on an intake form and/or by including some content about gender issues in the clinical interview. If gender concerns are noted, a referral should be made to an appropriate gender specialist for assessment and supports.”
Note the passive voice. Even if, after all the confusing prompts, the patient does not express gender concerns, the screener can note gender concerns. All roads lead to gender specialists.
Damage Control (2018)
Gender medicine enjoyed an easy ride in the national media for most of its history. Practically no one ever challenged gender identity theory in print. (Here are all my posts about the deadbeat media.) That changed in June of 2017, when the Stranger, a Seattle alt weekly read by bookish dirtbags nationwide, published Katie Herzog's investigation into the world of detransitioners. Herzog quoted detrans people scorning the theory behind gender medicine and suggesting exercise was a better treatment for gender dysphoria than hormones. She also addressed the gay elephant in the room and explained the radical feminist critique of gender medicine. The piece was totally iconoclastic.
About a year later, the Atlantic published a cover story about youth gender medicine by Jesse Singal. It featured an expert who’d previously stayed out of the limelight.
Singal introduces Laura Edwards-Leeper:
“When it comes to helping TGNC young people gain access to physical interventions, few American clinicians possess the bona fides of the psychologist Laura Edwards-Leeper.”
These days Edwards-Leeper is “training clinical-psychology doctoral students to conduct ‘readiness assessments’ for young people seeking physical-transition services” in Oregon. And she’s eager to discuss detransition:
“I’ve been predicting this for, I don’t know, the last five or more years … I anticipate there being more and more and more, because there are so many youth who are now getting services with very limited mental-health assessment and sometimes no mental-health assessment. It’s inevitable, I think.”
Singal interviews two teen girls who worked with Edwards-Leeper. One played with “stereotypically male toys like dinosaurs” as a child and chafed under the thumb of a “super Christian” step-father who made her wear dresses. At age 13, her grandmother took her to Edwards-Leeper, who eventually cleared her for transition.
Singal doesn’t state whether the girl identified as male before Edwards-Leeper assessed her. The questions:
“She asked me about how I felt when I was younger—was I comfortable with my body? What did I tend to like or be interested in?”
The other girl is a classic ROGD case who Edwards-Leeper bounced. She soon desisted. (After the article’s publication, this girl’s mother noted it had been her decision to nix medicalization, not Edwards-Leeper’s. She expressed disappointment that the Atlantic had cut references to 4thWaveNow and other parenting resources. These offered more critical perspectives on the gender industry.)
Singal also interviews Johanna Olson-Kennedy, the prolific Los Angeles gender doctor who once said girls who regret mastectomy can buy breast implants. No fan of red tape, she argues against Edwards-Leeper’s approach:
“We don’t actually have data on whether psychological assessments lower regret rates.”
Good point, Dr. Growthe-Firstpairfree. I’d add, gatekeeping has been around since the dawn of gender medicine. So why isn’t there any data to support it or compare different versions of the practice?
Herzog’s article raised the possibility that gender medicine was bullshit. Edwards-Leeper then told the world that the problem was doctors skimping on mental health assessments. It was an easier story to tackle.
The Unspeakable Interviews (2021)
Since her interview with Singal, Edwards-Leeper has appeared all over the media, including in the New York Times (three times), Reuters, the Economist (twice), Washington Post, and Vice, and on CBS (twice). In 2021, she sat for two hours’ worth of interviews with Meghan Daum on Daum’s podcast, the Unspeakable.
Part 1
Part 1 is a conventional interview with Daum.
Edwards-Leeper’s persona is part starry-eyed gender doctor, part streetwise moderate. For example, she attributes the rise in trans identity to increased social acceptance but also acknowledges that having gender “on the table … created confusion for young people” and they erroneously believe it “may explain why they feel different.” She thinks social contagion is real but she’s also concerned that parents of truly trans kids are writing off their dysphoria as socially influenced.
Describing her interactions with parents, she says, “They just want there to be a process, and for it to be thoughtful.”
I think she’s wrong. What parents want from their kid’s mental health clinic is evidence-based medicine and accurate information about the condition being treated. But a structured “process” can create the illusion of that.
Edwards-Leeper talks about the need for “individualized” care – a touchstone of hers. While in some areas of medicine this is reassuring (you don’t want your brain tumor excised with a cookie cutter), it can also stand for, We don’t have any systematized knowledge to apply so we just go on vibes in each case.1
When Daum asks Edwards-Leeper how many kids are trans, she responds that there is no hard data:
“It’s fairly subjective, you know, there’s no brain scan or blood test obviously that we can do to know, like, if someone’s trans or not. It’s just not straightforward and that’s what people have a very hard time with, anything that’s more complex (laughs).”
Daum asks her if puberty blockers are safe. By now, women treated for precocious puberty have filed a class action against a blocker manufacturer over their bones crumbling away in young adulthood. Edwards-Leeper:
“I’m not a medical doctor or endocrinologist, that’s out of my realm of expertise. … My medical colleagues tell me … that they are relatively safe …”
She vaguely acknowledges bone density issues but adds:
“From a psychological and developmental perspective, the longer they can be on blockers, the better. … I get concerned when they’re not offered longer.”
Edwards-Leeper shares with Daum what’s driving her:
“What will happen if we don’t have a process like that [with comprehensive assessments] is exactly what we’re seeing, which is more and more people detransitioning, which is then going to call into question the whole field, and the whole idea of even offering medical interventions for trans youth. That’s been my biggest fear for the past five to ten years.”
Part 2
In a follow-up episode posted soon afterward, Daum invited two gender-skeptical mothers of trans-identified youth to speak with Edwards-Leeper. The mothers used pseudonyms.
Edwards-Leeper’s discussion of “late-onset gender dysphoria” echoes her earlier writings. She thinks some kids don’t express their trans identity until late adolescence because that’s when they learn the language for it. For children, simply playing with toys associated with the opposite sex is “evidence” of being transgender.
For children, simply playing with toys associated with the opposite sex is “evidence” of being transgender.
Asked about her assessments, Edwards-Leeper says she makes sure the kid grasps what medicalization will entail, plus tries to understand them “holistically.” She examines their family dynamics, significant events in their lives, their “social world,” and their academic performance. She figures out their mental health diagnoses that are or are not being treated, and how gender dysphoria fits into that. Then she has the kid and parents fill out forms that provide “quantitative data” on “psychological and gender measures.” Finally she uses all of this to write a “very long report.”
How does any of that help determine whether the kid should take blockers or cross-sex hormones? Unclear. Recall: Edwards-Leeper believed in 2012 that many gender-dysphoric kids who suffered from other psychiatric disorders were “cured” by gender medicine.
The mothers press Edwards-Leeper on a term she keeps using, “gender identity development.” What does that mean? Edwards-Leeper:
“We don’t fully understand what that means so it’s a little bit hard to answer (laughs). … There are absolutely people whose identity doesn’t match their body. ... We don’t have good research on it. … I think there has to be a biological component, at least for some people.”
There is not a biological component to gender identity. Maybe she has gender identity confused with sexual orientation, which is biological and leads gay kids to feel different in a way they struggle to articulate.
The mothers cite studies showing most “gender dysphoric” kids outgrow it. Edwards-Leeper says that research is “really confusing” and claims the kids treated in the Dutch puberty-blocker study turned out “remarkably well.”
The mothers grill Edwards-Leeper on the “conflation” of gender identity with sexual orientation, and the concern that transitioning gay kids is a form of “conversion therapy.”
Edwards-Leeper:
“You’re absolutely right that there is a lot of overlap. It gets very intertwined, like the gender and the sexuality piece, and the internalized homophobia and all of that. … That’s another really important part of both therapy and assessment with young people is to understand where are they at with their sexual orientation development, and try to dig into that.”
When she described the content of her assessments earlier, she didn’t mention sexual orientation.
Edwards-Leeper acknowledges it’s hard for teens to “tease apart” issues related to sexuality. That’s why, she says, “it’s young adults who come to realize this gender thing was actually about sexual orientation.”
What about Shawn, the 14-year old girl who couldn’t stand the word lesbian? Edwards-Leeper never says that a kid with internalized homophobia shouldn’t transition, or that a possibly-gay teenager should wait until she’s had some romantic experience. She doesn’t mention how or whether a psychologist should address gay patients’ shame.
Maybe she would trans Shawn. Maybe she did trans Shawn.
Related:
After I drafted the critique of the “individualized” buzzword, an expert report by James Cantor came to light in the Alabama pediatric gender medicine lawsuit. [Here’s a copy uploaded by Jesse Singal on Google Drive.] It revealed discussions between WPATH guideline-drafters about how to spin the fact that they’d deleted age minimums from SOC8 after publication. One drafter offered: “I feel the final document puts the emphasis back on individualized patient care …” Another responded, “Exactly—individualized care is the best care—that’s a positive message and a strong rationale for the age change.”
As one of the skeptic Moms on the podcast with LEL, one thing that I hope will come out from that interview is she states plainly that “there is no evidence that there is a risk of suicide if you don’t affirm”- this is the entire reason so many people believe this care is vital!!! Thank you for such a comprehensive outline of the cruelty and butchery these ideologues are performing on children and vulnerable adults of all ages!
It is very frustrating that more conversations are not had about this. Thea people believe the true transsexual is a homosexual. It’s very plain to see.