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Emergency rules limiting transgender care in Missouri set to take effect this month

The 9-year-old son of Daniel and Karen Bogard, pictured at his St. Louis County home on Wednesday, March 22, 2023, is one of the transgender Missourians who has been targeted by anti-trans policies, rhetoric, and legislation.
Brian Munoz
St. Louis Public Radio
The 9-year-old son of Daniel and Karen Bogard, at his St. Louis County home last month, is one of the transgender Missourians who has been targeted by anti-trans policies, such as Attorney General Andrew Bailey's limits on gender-affirming care. The Bogard family is now considering leaving the state.

Updated at 6:25 p.m. April 13 with a statement from the American Civil Liberties Union and the LGBTQ legal organization Lambda Legal

Missouri Attorney General Andrew Bailey has announced that temporary rules limiting gender-affirming care for transgender people will go into effect on April 27.

Bailey said the rules, which expire Feb. 6 of next year, are an effort to protect minors from what he calls harmful medical procedures.

The emergency regulations prohibit health care workers from offering medical gender-transitioning interventions unless they ensure someone has exhibited medically documented gender dysphoria for the past three years, received at least 15 separate hours of therapy and “resolved” any existing mental health issues.

Some provisions, such as the ones requiring three years of established gender incongruity and the therapy rules, do not apply to people who are already receiving gender-affirming medical care.

He argues his office is allowed to issue the restrictions because hormone therapy, surgeries and puberty blockers are not treatments approved by the federal Food and Drug Administration and are thus considered experimental procedures.

“Among other reasons, the recent immense increase in the use of these life-altering interventions, which have serious side effects, as well as the recent acknowledgement that these interventions are used in circumstances not supported by solid evidence, makes this issue time-sensitive,” the office said in a preface to the regulations.

Surgery and hormone therapy are part of a spectrum of gender-affirming health care practices that are supported by major professional medical associations including the American Academy of Pediatrics, the American Medical Association and the American Psychiatric Association, among dozens of others. Studies show gender-affirming care is correlated with lower risks of suicidal thoughts and depression.

Andrew Bailey, newly appointed Missouri Attorney General, gives remarks after being sworn in on Tuesday, Jan. 3, 2023, at the Missouri Supreme Court in Jefferson City.
Brian Munoz
St. Louis Public Radio
Missouri Attorney General Andrew Bailey, photographed in January at the Missouri Supreme Court in Jefferson City, announced Thursday that temporary rules limiting gender-affirming care for transgender people will go into effect this month.

The attorney general has said the regulations are aimed at protecting minors from receiving procedures too quickly. However, the regulations do not mention only applying to those under 18.

"As attorney general, I will always fight to protect children because gender transition interventions are experimental,” Bailey said. “My office has uncovered a clandestine network of clinics across the state who are harming children by ignoring science.”

Bailey’s office is investigating care at the Washington University Transgender Center at St. Louis Children’s Hospital. In an op-ed published earlier this year, a former worker there accused the clinic of rushing patients into care. Bailey’s office and Republican U.S. Sen. Josh Hawley said they were launching investigations into the clinic, which provides treatment to minors.

The regulations require providers to receive informed consent from patients by saying and presenting in writing findings from various studies that portray gender-affirming care as risky and not based on evidence.

Transgender patients and advocates say gender-affirming procedures, including puberty blockers and hormones, have been used for decades and are not experimental. They have accused Bailey of selectively choosing which studies to highlight and ignoring the positions of professional medical organizations, which support access to age-appropriate gender-affirming treatments and say such care is best decided on by patients, their families and their doctors.

Transgender people also say that requiring doctors to treat depression and other mental health problems before providing medical interventions is ignoring that untreated gender dysphoria is often the cause of mental anguish.

“You tell them they have to be all mentally better before you can give them treatment, it's putting the cart before the horse,” E.H., a transgender man who lives in south St. Louis, said in March when Bailey initially announced the regulations. “Trying to say you should just feel better — it's like saying you can't treat someone for depression until they're not depressed anymore. Treat the condition at hand, and the condition at hand is that I'm in the wrong body.”

The American Civil Liberties Union and the LGBTQ legal organization Lambda Legal have said they plan to challenge the regulations in court.

“The rule is a shocking attempt to exploit Missouri’s consumer protection laws in order to play politics with life-saving medical care,” a statement from the two organizations reads.

The two legal groups said the rule is based on misleading and debunked claims, will compound the stigma and prejudice transgender people face and could cause them to lose vital medical treatment.

Sarah Fentem is the health reporter at St. Louis Public Radio.