When Missouri Attorney General Andrew Bailey unveiled his emergency rules on transgender health care earlier this month, some were stunned to learn the guidelines affected adults as well as children.
But Chelsea Freels said she wasn’t surprised.
The 17-year-old Clayton High School student testified this year before the Missouri legislature against taking gender-affirming care from transgender youth like her. And she often had to explain to legislators that she didn’t need protection — especially since the care she received made her happier and improved her quality of life.
“But you know, the goal is to erase trans people and score as much political capital while you can,” she said.
Bailey said the rules, which are slated to go into effect Thursday, are meant to make both parents of transgender children and transgender adults more informed before anyone receives gender-affirming care. He described it as an “innovative approach” for people to “have all the information necessary to make good decisions.”
LGBTQ advocates see the rules as a dramatic and sudden escalation in GOP rhetoric and an attack on transgender people. They also see an expected lawsuit as critical to not only keeping gender-affirming care available for minors and adults, but to provide a disincentive for politicians in other red states to follow suit.
“These people have zero experience in medicine,” said Danielle Meert, a former St. Louis chapter president of the TransParent support group. “This is not their job. Their job is to fix potholes and make sure bridges aren't crumbling and reopening schools five days a week. That's what they need to be doing or not getting involved in my kid’s health care.”
Innovative or unprecedented?
The emergency rules Bailey put forward are unusual for a number of reasons. For one thing, they didn’t go through the legislature but rather are based on his powers to oversee consumer protection issues in the state.
Bailey’s guidelines came as Missouri lawmakers are considering several bills, including a gender-affirming care ban for minors that’s slightly less restrictive than that of some other states. That’s because a Democratic filibuster in the Senate exempted children who are already receiving treatment and added a clause for the legislation to expire in four years. A pending House bill is more restrictive.
The rules proposed by Bailey require someone to receive 15 separate hourly sessions of therapy over at least 18 months, be screened for autism or have documented gender dysphoria for three years.
“These are intended to protect all patients and make sure that all patients have access to mental health services,” Bailey said.
They also include a clause requiring that a provider “ensure that any psychiatric symptoms from existing mental health comorbidities of the patient have been treated and resolved.” When asked to provide an example of what that meant, Bailey responded: “Treating these other mental health problems before we raced down the road of administration of experimental drugs.”
Medical professionals like Brandon Hill strongly dispute Bailey’s characterization of gender-affirming care as experimental. The American Medical Association said in 2021 that gender-affirming care is “medically-necessary, evidence-based care that improves the physical and mental health of transgender and gender-diverse people.”
Hill is acting CEO of Vivent Health, a Milwaukee-based agency with facilities in Missouri that provides health care, including gender-affirming care, primarily to LGBTQ people. He said what Bailey is doing is “unlike anything we've seen before, particularly in that it does include adult individuals over 18.”
“When we move into the adult space, this is saying that your government gets to decide your existence and in what way you can access readily available medications that have been used for decades,” Hill said.
And while Bailey’s rules exempt people currently receiving gender-affirming care, Hill said they are so onerous that providers may stop providing treatments altogether.
“This could lead to the discontinuation of that care if the health care providers are not able to meet all these new requirements that are both antiquated and not based in science at all,” Hill said. “It would leave thousands and thousands of adult trans and non-binary Missourians searching for a place to continue their care. Not start care. But continue their care.”
Both Meert and her husband, James Thurow, who have a 16-year-old transgender son, added that gender-affirming care is already expensive. And requiring people to attend therapy sessions or be screened for autism adds additional costs that may make gender affirming care impossible to afford.
“They've clearly had trans kids on the radar for a long time. And the way you get rid of having trans adults is you get rid of trans kids, you make it as difficult as possible for them to transition when they know who they are,” Thurow said. “I mean, I knew who I was at their age. I knew I was not transgender. And they're just trying to wage a war against transgender people."
Legal challenge
The ACLU and Lambda Legal said in a joint statement after the rules were released that they would file a lawsuit to strike them down. Bailey said he’s confident the rules can withstand a legal challenge.
“The rule was intended to not be underinclusive,” he said. “So we're protecting all patients.”
Thurow said it’s important for the suit to succeed and not just for Missourians.
“The more it can get codified on a federal level, the better,” Thurow said. “Because it's going to happen in every possible red state where they can jam this through.”
It’s unclear whether Bailey’s rules could spark a political backlash. One key GOP official, Secretary of State Jay Ashcroft, said he supports the plan for minors but not adults.
“There’s a difference between what I think and where I think the government should be involved,” he said.
Some opponents of prohibiting gender-affirming care for adults and minors hope that the issue will backfire on Republicans, especially as younger voters who support LGBTQ rights turn 18 and go to the polls.
Chelsea Freels said her generation can help turn back policy that could affect people like her.
“Make no mistake, we will probably lose this battle, but we will win the war,” Freels said. “The problem is how many casualties and how many bodies laid dead before we got there?”
Freels isn’t staying around much longer to find out if there’s political change.
“I do not want to be here anymore. I'm going to college soon,” she said. “And I’ve got a red state hole puncher and the map of the U.S. And those are places that are not on my list anymore. And Missouri is unfortunately one of them.”
