Gender-affirming healthcare is now much more difficult, nigh impossible, to access in Missouri, even for adults. Medical treatments, including hormones, puberty blockers, and surgeries, though widely accepted as safe and critically important for many transgender people, are behind a bevy of new limitations in the state. Missouri Attorney General Andrew Bailey enacted an emergency rule on Thursday afternoon putting massive restrictions on trans care for both minors and adults. This follows similar laws and bills focused on banning or limiting gender affirming care for minors that are advancing or have passed in states like Nebraska and West Virginia.
The regulation is one of the most sweeping prohibitions on trans healthcare in the country. Through the new rule, Missouri has become the first state to effectively ban gender-affirming care for adults in the U.S., presenting an insurmountable amount of hoops to jump through for many.
Among other things, the new restrictions force people seeking gender-affirming care to undergo extensive mental health counseling, impose a minimum 18-month waiting period for care, bar anyone with an “existing mental health comorbidity” like depression or autism from receiving gender-affirming care, and require than trans people be monitored and tracked for at least 15 years beginning at the start of any medical transition process. Moreover, the emergency regulation mandates that healthcare providers give misleading information to trans patients seeking gender-affirming care.
“As Attorney General, I will protect children and enforce the laws as written, which includes upholding state law on experimental gender transition interventions,” Bailey said in a statement.
However, gender-affirming care (what he calls “gender transition intervention”) is not “experimental.” Medical treatment for trans people follows a well-established roadmap of best-practices supported by lots of research. Gender-affirming care is accepted and endorsed by the American Medical Association, the U.S. Department of Health and Human Services, the American Academy of Pediatrics, the Association of American Medical Colleges, and countless other institutions. Gender-affirming care saves lives, according to psychiatric experts. Yet that hasn’t stopped the GOP and conservatives more broadly from targeting trans healthcare in their ongoing efforts to eliminate “transgenderism.”
At least 12, mostly Republican-led, states have imposed new limits on gender-affirming care in recent months, amid an explosion of anti-trans rhetoric and policy. Yet all of the legislation enacted so far focuses on care for minors, according to tracking data from the ACLU and an Axios report. Bailey’s emergency rule makes Missouri the first U.S. state to severely limit (and effectively ban, in many cases) gender-affirming care for adults, too.
In a handful of states including Kansas, Indiana, Kentucky, Texas, Oklahoma, and Missouri, legislators have introduced bills that would restrict access to trans healthcare for adults. Yet, none of these policies have yet passed into law. Apparently, Missouri’s AG decided he was tired of waiting on his state’s legislature to act. Thursday’s emergency rule did not require any elected representatives to vote on the issue. Instead, Bailey flexed his authority under the Missouri Merchandising Practices Act, which is meant to protect consumers from predatory corporations—not impose limits on healthcare access.
Under the AG’s order, no trans person will be allowed to receive hormones or surgery unless they first go through at least 15 hours of psych assessment. They will also be forced to wait for 18 months between making their decision to seek medical care and receiving it. Further, anyone with a pre-existing mental health diagnosis like depression will have to prove their condition has been “resolved,” which is not really a thing with lifelong diagnoses. Autism is now a disqualifying condition for gender-affirming care in Missouri, as well. Moving forward, trans minors seeking treatment now must also be evaluated for “social media addiction” and “social contagion”—which bolster the unscientific conspiracy that trans kids and teens become trans because of social pressures. Patients and doctors are also now required to track “all adverse effects” resulting from gender-affirming care for at least 15 years. The list of unnecessary hoops and barriers goes on.
Though this isn’t technically an outright ban of gender-affirming care, the emergency rule makes receiving such care incredibly difficult. It is an effective ban on treatment for any trans person diagnosed with a mental illness (which is a majority, according to some studies), any trans person with autism, or any trans person who simply lacks the resources to navigate such strict requirements.
To argue for these restrictions, Bailey’s emergency regulation references multiple widely-debunked, far-right talking points about gender-affirming healthcare, and requires medical providers parrot them. For instance, that puberty blockers and hormone therapy aren’t approved by the Food and Drug Administration and are dangerous. Except puberty blockers, estrogen, and testosterone are FDA approved for multiple medical conditions like treating precocious puberty, prostate and breast cancers, endometriosis, managing symptoms of menopause, and in fertility treatments. These treatments are widely considered safe, as supported by extensive research.
The use of hormones and blockers in gender-affirming care, though not specifically designated by the FDA, is done through a practice known as “off-label” prescribing, which is exceedingly common in medicine. Often, medicines known to be safe from earlier trials won’t be re-evaluated by the FDA after researchers discover they are also useful for new applications. About one in five medical prescriptions in the U.S. are off-label, according to the Agency for Healthcare Research and Quality.
Regardless of the off-label status of hormones and puberty blockers in gender-affirming care, multiple studies support the safety and efficacy of these treatments for trans people. Like almost all medical interventions, puberty blockers and hormone therapies can come with side effects, but doctors operating under the informed consent model share this information with their patients. Together, a patient and doctor decide if the established benefits outweigh the potential risks.
Gender-affirming surgeries too, have been proven safe and beneficial for trans people who seek them out.
By cutting off access to gender-affirming care, AG Bailey is cutting trans people off from those benefits of treatment, which include improved quality of life and mental health, as well as reduced suicide risk. The emergency rule also puts trans people in Missouri at increased risk of persecution, noted the ACLU of Missouri in an extended statement on Bailey’s regulation.
“This emergency regulation will have a drastically negative impact on transgender youth, compounding the prejudice, discrimination, violence, and other forms of stigma they continue to face in their daily lives,” the non-profit legal organization wrote as part of a Twitter thread. The Missouri ACLU noted it plans to “defend the rights of transgender people through any necessary legal action.”