Transgender adults brace for treatment cutoffs in Missouri

Ellie Bridgman spent her Thursday night shift at a local gas station in Union, Missouri, planning for the day she'll lose access to gender-affirming treatments the transgender and nonbinary 23-year-old credits with making "life worth living."

A first-of-its-kind emergency rule introduced this week by Missouri's Republican Attorney General Andrew Bailey will impose numerous restrictions on both adults and children before they can receive puberty-blocking drugs, hormones or surgeries "for the purpose of transitioning gender."

Transgender rights advocates have vowed to challenge the rule in court before it takes effect April 27. But promises of swift legal action have done little to ease the worries of trans Missourians such as Bridgman who say it may be time to flee the state.

Before gender-affirming medical treatments can be provided by physicians, the regulation requires people to have experienced an "intense pattern" of documented gender dysphoria for three years and to have received at least 15 hourly sessions with a therapist over at least 18 months. Patients also would first have to be screened for autism and "social media addiction," and any psychiatric symptoms from mental health issues would have to be treated and resolved.

Some individuals will be allowed to maintain their prescriptions while they promptly receive the required assessments.

Bridgman, who uses she/they pronouns, is autistic and has depression. She said she sees only two options: move across the country, away from all her friends and family, to a state that protects access to gender-affirming care, or accept the serious health risks that could come with illegally buying hormones online.

She headed to a pharmacy Friday afternoon to pay out of pocket for all her remaining refills.

"Placing restrictions on transitioning for people with depression is just a way for them to completely bar us from transitioning at all," Bridgman said. "For lots of trans people, dysphoria is the cause of depression. You can't treat the depression without treating the underlying dysphoria."

Before Bridgman started hormone replacement therapy last summer, she said "life felt meaningless" and suicidal thoughts crowded her head. Gender-affirming care was her "last chance at life," she said.

The regulation comes as Republican lawmakers across the country, including in Missouri, have advanced hundreds of measures aimed at nearly every facet of transgender existence, with a particular emphasis on health care.

At least 13 states have enacted laws restricting or banning gender-affirming care for minors. Bills await action from governors in Montana, North Dakota and neighboring Kansas, and nearly two dozen other states are considering legislation to restrict or ban care.

National groups advocating for LGBTQ+ rights contend the Missouri regulation — based on a state law against deceptive and unfair business practices — goes further than most restrictions enacted elsewhere.

Three states have imposed restrictions on gender-affirming care via regulation or administrative order, but Missouri's regulation is the only one that also limits treatments for adults.

Cathy Renna, a spokesperson for the National LGBTQ Task Force, said the rule demonstrates how Republicans are now successfully broadening the scope of gender-affirming care restrictions beyond minors, which advocates had been warning about for months.

"When they see one thing work in one state, they'll try to replicate it in another," Renna warned.

Bailey's restriction comes after a former employee at a transgender youth clinic in St. Louis alleged that physicians at the Washington University Transgender Center were rushing to provide treatment without appropriate patient assessment.

Bailey said he is investigating the clinic but has not issued a report. The claims of mistreatment have been disputed by others, including another former employee and patients. Neither Bailey nor the university responded to phone and email messages seeking comment.

Dr. Meredithe McNamara, an assistant professor of pediatrics specializing in adolescent medicine at the Yale School of Medicine, said evidence widely supports maintaining access to hormone therapy and other gender-affirming care.

As part of a consent process, Bailey's rule requires that patients be shown materials containing nearly two dozen specific statements raising concerns about gender-affirming treatments — a practice doctors such as McNamara have denounced as a form of conversion therapy.

"There is no evidence that shows that psychotherapy as the only treatment is effective," she said.

Stacy Cay, an autistic trans woman in Kansas City, Missouri, has been stockpiling vials of injectable estrogen in anticipation of restrictions. The 30-year-old comedian and model realized she only required a small dose and has saved up enough estrogen to last about a year. When that runs out, she will have to travel across state lines to fill prescriptions or consider moving elsewhere.

Cay said her persistent depression will cut off her access to hormones under the regulation and that her autism diagnosis could complicate her path to receiving future care. While the regulation does not specify whether autism disqualifies a person for gender-affirming care, it does mandate an assessment.

A 2020 study from natural sciences journal Nature Communications estimated transgender and gender-diverse people, or those whose gender expressions do not conform to gender norms, are three to six times more likely to be autistic compared to cisgender people. They were also more likely to have other developmental and psychiatric conditions, including depression.

"They know a lot of us are autistic, and it's part of their strategy to paint us as unstable — that we can't be trusted to make our own medical decisions," Cay said.

Attorneys from Lambda Legal and the American Civil Liberties Union say they plan to challenge the new rule in court.

Missouri falls under the 8th U.S. Circuit Court of Appeals — the same court that upheld a preliminary injunction last year preventing Arkansas from enforcing a first-in-the-nation ban on trans children receiving gender-affirming treatments. Federal judges have also blocked enforcement of a similar law in Alabama.

Republican legislators leading Missouri's effort to ban gender-affirming treatments for minors said Friday that they have no plans to expand their legislation to include adults.

Separate bills passed by the Missouri House and Senate would ban treatments for children younger than 18 but would impose no restrictions for adults who are covered by private insurance or willing to pay for their own health care.

"I believe it is detrimental to a person's body, probably even their psyche, to go through treatments like that," said state Sen. Mike Moon, lead sponsor of the Senate legislation. "Adults have the opportunity to make decisions such as these."

Schoenbaum reported from Raleigh, North Carolina, and Lieb reported from Jefferson City. Associated Press editor Jeff McMillan contributed from Scranton, Pennsylvania.