Editor’s note (May 16, 2023): This story has been updated to reflect that Missouri Attorney General Andrew Bailey rescinded his order regarding gender-affirming care for adults and minors in Missouri.
Editor’s note (May 10, 2023): This story has been updated to reflect the Missouri General Assembly’s passage of a bill banning gender-affirming care for minors and a bill requiring transgender athletes play on sports teams that match their sex marker at birth.
Editor’s note: This story has been updated to reflect an extension on the pause of Attorney General Andrew Bailey’s rule regarding gender-affirming care.
After it was filed, Missouri Attorney General Andrew Bailey’s emergency rule restricting who can access gender-affirming care in the state set off a scramble among providers and patients to figure out what it could mean for them.
The rule was rescinded by Bailey’s office on May 16, days after the General Assembly passed a bill that would ban gender-affirming care for minors, with some exceptions. Providers are now preparing to respond to the Missouri General Assembly’s passage of a bill that would ban gender-affirming care for minors.
Providers say the prospect of Bailey’s order and actions taken by the legislature could have a chilling effect on the care that current and future patients receive, and could cause medical residents and other health professionals to avoid practicing in Missouri.
Limiting access to gender-affirming care for minors was a top priority for Republican leadership and Gov. Mike Parson throughout the legislative session. Parson threatened to bring lawmakers back to Jefferson City if they did not pass a bill banning gender-affirming care for minors and provisions to prevent transgender athletes from playing on sports teams that do not match the sex marker they were assigned at birth.
On May 10, legislators approved SB 39, which bans athletes from playing on sports teams that do not match their sex markers at birth, and SB 49, which bans gender-affirming care for minors. Lawmakers reached a compromise on SB 49 after a Democratic filibuster, and included a provision to grandfather in children who are already receiving gender-affirming care as well as a four-year sunset provision. The bill also permanently bans gender-affirming surgeries for minors. If signed by the governor, the legislation would go into effect on August 28.
“As providers, we always want to provide the best care we can for our patients, to act ethically, and to of course operate within the laws and regulations of the states and areas in which we practice,” said Leslie Cockerham, the chief medical officer at Vivent Health, a nationwide provider of HIV and gender-affirming care. “And the regulation proposed by the attorney general does not allow us to do all those things.”
Providers would have to disseminate very specific information about the risks of gender-affirming care, even though much of it is not accepted by the larger medical community.
Patients would need to receive at least 15 separate hourly sessions of psychological or psychiatric assessments over no fewer than 18 months before more advanced treatments can be offered. Providers would need to “resolve” mental health comorbidities, screen patients for autism and ensure that patients who are minors are screened for social media addiction.
Providers who do not abide by the limitations set out in the rule could be subject to lawsuits from the attorney general concerning fraudulent practices.
Medical professionals who provide gender-affirming care to both adults and minors say not having access to those treatments can be a matter of life and death for their transgender patients. They worry that they’ll be forced to make difficult decisions when it comes to the ethical obligations of giving the best care possible.
“We know that it is life-affirming and even lifesaving care for many of our patients,” Cockerham said. “We have studies that show that individuals who have access to gender-affirming care have better mental health outcomes, lower rates of suicide.”
In the Missouri legislature, both the House (HB 419) and the Senate (SB 49) have passed versions of a bill that would ban gender-affirming care for minors, although it is unclear if the two chambers will be able to agree on a final piece of legislation. The Senate bill includes a compromise that would grandfather in minors who are already receiving care and includes a sunset provision that would require lawmakers to reassess the legislation after four years.
Gov. Mike Parson has threatened to call a special session if lawmakers don’t pass a ban on gender-affirming care for minors and restrict transgender athletes to sports teams that match the sex marker on their birth certificate before the legislative session ends on May 12.
How legal rulings and vague legislation can affect Missouri’s transgender care providers and patients
Planned Parenthood Great Plains, a regional provider of reproductive, sexual and gender-affirming care, told The Beacon that their clinics have expanded appointment availability to try and accommodate worried Missourians.
“We’ve had a number of patients who have established care already with other providers, but heard from their providers that they’re not sure they’ll be able to continue it, or they’re anxious about whether their provider will take on potential additional risks,” said Emily Wales, the president and CEO.
“So they’re transferring care to Planned Parenthood. It’s a good thing to be a brand that’s recognized as being willing to fight back, being used to pivoting and adjusting to support patients through all sorts of unnecessary hurdles to get care. But it’s also heartbreaking.”
Wales said the threatened criminalization of providers who care for trans patients is similar to what Missouri and other GOP-led states have done when it comes to access to abortion.
Wales said PPGP is working on bolstering a fund for patients who may need to travel to states like Kansas or Illinois to receive their gender-affirming care, something many groups have done when it comes to having an abortion across state lines.
“The idea that we are now sending patients [across state lines], potentially for multiple services. This isn’t isolated to abortion,” Wales said. “It is anything that the legislature doesn’t understand or can’t control, they’re willing to regulate out of existence.”
What does criminalization of gender-affirming care mean for future providers?
A study since the June 2022 U.S. Supreme Court Dobbs v. Jackson Women’s Health Organization decision shows that the number of OB/GYN students pursuing residency has dropped in states that have restricted access to abortion. Wales worries that specialists who provide gender-affirming care will also steer clear.
“Folks who want to do this work are smart and savvy and they are going to find the best places to do it,” she said. “And what a horrible situation to have a state’s population that’s going to miss out on critical access to care because it’s a political football.”
Pamela Merritt is the executive director of Medical Students for Choice, an organization that advocates for curriculum reform on medical school campuses to include abortion care and family planning training. She has seen how state restrictions on abortion can influence where medical students choose to train and practice, and worries that new limitations on gender-affirming care could have a similar effect.
“When medical students are selecting a school, what they’re usually thinking of is less about their curriculum, though to a certain extent they are, but more about the overall environment and whether or not it supports evidence-based science-based education and training,” Merritt said.
It could have a downstream impact on the quality of care provided to all Missourians, she added.
“Now is the time where we can actually influence, and tell our state and local government that the message they’re sending out is that if you are a young, talented medical student or physician in training, you better be prepared to dial back to 1956 when you go to Missouri,” Merritt said. “That is not a good message. But it’s hard to envision doing cutting-edge, lifesaving care in an environment where the state legislature and the attorney general are arguing about things that are absolutely settled through rigorous research.”
Wales said conversations about limiting care are painful for providers and patients.
“We’re having the same conversations with our trans patients that we’ve had for a long time with abortion patients, saying, ‘The state is interfering in your care in this way. You’ve got to jump through these hurdles,’” Wales said. “And it’s an awful thing to see on a patient’s face for whatever care they’re seeking. These medically unnecessary, often inaccurate or really problematic restrictions are going to affect when and how they can get care.”
