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Glenda Starke wears a transgender flag March 20, 2023, as a counterprotest during a rally in favor of a ban on gender-affirming health care legislation at the Missouri Statehouse in Jefferson City, Mo. (AP) Glenda Starke wears a transgender flag March 20, 2023, as a counterprotest during a rally in favor of a ban on gender-affirming health care legislation at the Missouri Statehouse in Jefferson City, Mo. (AP)

Glenda Starke wears a transgender flag March 20, 2023, as a counterprotest during a rally in favor of a ban on gender-affirming health care legislation at the Missouri Statehouse in Jefferson City, Mo. (AP)

Grace Abels
By Grace Abels April 24, 2023

If Your Time is short

  • Missouri’s attorney general issued an emergency rule April 13 limiting access to gender-affirming care for residents of all ages. This rule, which did not need to pass through the state Legislature, will take effect April 27 barring a legal challenge. 

  • The rule imposes a one and a half to three-year waiting period for patients and requires mental health and autism screenings, and resolution of all other mental health symptoms. Experts say these restrictions will significantly complicate accessing care. 

  • Several requirements in the bill lack clear definitions, leaving providers confused about when care can and cannot be administered. 

As legislatures nationwide debate bills targeting transgender communities, Missouri has taken a novel approach to limit access to gender-affirming care. 

On April 13, Missouri Attorney General Andrew Bailey issued an emergency rule that significantly restricts which transgender adults and minors can access gender-affirming care.

The rule requires patients to have a year and a half of therapy, three consecutive years of "medically documented, long-lasting, persistent and intense," gender dysphoria, and have all symptoms from mental health issues "treated and resolved."

An emergency rule can be applied when a Missouri agency "finds that an immediate danger to the public health, safety, or welfare requires emergency action," or its urgent implementation is "necessary to preserve a compelling governmental interest."

Bailey said the threat of "gender transition intervention" fits those requirements. An emergency rule does not need to pass the state Legislature to take effect, but is subject to judicial review. 

The American Civil Liberties Union and Lambda Legal, an organization focused on civil rights for LGBTQ+ people, released a joint statement promising to take "any necessary legal action" against the rule. But barring legal challenge, the rule will take effect April 27.

Activists were alarmed, describing the numerous restrictions outlined in the bill on Twitter and writing, "Missouri AG just essentially banned gender affirming care for most trans adults via emergency rule."

The emergency rule does not ban all care, but experts and physicians say it imposes enough barriers that fewer patients would qualify. Confusion about the bill’s scope adds to the uncertainty.

Missouri rule implements high barriers to care

In March, Bailey said he would use emergency rules to address gender-affirming care. Such health care is generally defined as any social, emotional or physical care that centers, encourages and supports a person’s gender identity; it can range from use of a patient’s gender pronouns to medication to surgery. 

Bailey’s initial announcement focused specifically on care for minors and was similar to other legislation being enacted around the country. But the rule he unveiled three weeks later applied to Missourians of all ages. 

Under the legislation, providers must ensure that:

  • "All psychiatric symptoms" from other mental health conditions must be "treated and resolved."

  • The patient has, for the past three consecutive years, "exhibited a medically documented, long-lasting, persistent and intense pattern of gender dysphoria."

  • The patient has received a "full psychological or psychiatric assessment," totaling 15 hourly sessions over 18 months. 

  • The patient has been screened for autism.

  • The patient is not experiencing "social contagion" as it relates to their gender identity. It did not offer more detail.

The rule lets patients who are receiving treatment to continue to do so as long as they "promptly" begin working to comply with the emergency rule’s standards.

It’s unclear how many adults would be disqualified or restricted from accessing care under these new standards, but experts say the number of patients eligible for care will drop.

Meanwhile, Missouri legislators are deliberating over bills that would ban gender-affirming care for minors.

Struggles with mental health may block many

Studies have found that transgender people tend to have higher rates of mental health diagnoses than the general population.

A 2019 Swedish study of people diagnosed with "gender incongruence" were three times as likely to be prescribed antidepressants and anti anxiety medications. Another study found that 58% of all 10,270 transgender patients had at least one psychiatric diagnosis. And the 2015 U.S. Transgender Survey found that 48.3% of transgender adults had seriously contemplated suicide in the past year and 40.4% had attempted it sometime in their lives.

Research suggests that social stigma, discrimination, and anti-transgender bias could be driving these higher rates, and there is growing evidence that gender-affirming care can improve mental health and well-being.  

To qualify for care under Missouri’s new policy, people must have mental health-related symptoms "treated and resolved," a standard that experts say is confusing and not always achievable. 

"’Resolved’ is unnecessarily rigid and excessive as a threshold for offering gender-affirming care," wrote Dr. Carl Fleisher, psychiatrist and medical director at the Boston Child Study Center in Los Angeles in an email to PolitiFact. 

Gender dysphoria, a diagnosis now required to qualify for gender-affirming care in Missouri, can itself contribute to other mental health problems, such as anxiety and depression. 

"That may mean a young person experiencing clinically significant distress due to being trans may be deprived of the very treatments needed to treat the distress," said Dr. Colleen McNicholas, chief medical officer of Planned Parenthood of the St. Louis Region and Southwest Missouri. (Bailey is investigating care offered through the clinic, and Planned Parenthood has sued in response to block access to the clinic’s records.)

PolitiFact did not hear back from Bailey’s office about what having symptoms "treated and resolved" would mean.

Harms of a waiting period, and confusing requirements 

In cases in which patients aren’t blocked from care because of mental health issues, the new rule’s 18-month mandated waiting period could significantly delay care.

For people not formally diagnosed with gender dysphoria, that timeline to wait for gender-affirming care stretches to three years. This is especially significant because a 2013 French study found that transgender people were at the "greatest risk of attempted suicide between when they plan to access medical care and when they are able to do so." Other data shows the suicide rate is higher among people who want to access care, but can’t.

Trans people are also less likely to access regular health care services, polling shows, making documentation of dysphoria over three consecutive years difficult.

It’s unclear how some of the rule’s other provisions will apply.

For example, patients must be screened for autism, but it is unclear whether not being screened would bar them from care. Research has found higher rates of autism among the transgender population, but experts are still exploring the cause. 

The rule also mandates providers to check for evidence of "social contagion" or a "social media addiction," which both lack clear definitions and are hard to quantify and measure. 

Bailey’s office did not respond to our questions on these matters.

"Most providers have referred this to their lawyers and are trying to figure out what this means," said Dr. Christina Roberts, a pediatrics professor at the University of Missouri-Kansas City School of Medicine. 

PolitiFact was unable to get more clarity from Bailey’s office about how this rule will play out once it’s in effect. But with days to go until it is scheduled to become reality, some transgender residents were considering leaving the state.

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Our Sources

Email interview with Dr. Christina Roberts, a professor of pediatrics at the University of Missouri-Kansas City School of Medicine, April 17, 2023

Email interview with Dr. Colleen McNicholas, chief medical officer of Planned Parenthood of the St. Louis Region and Southwest Missouri, April 19, 2023 

Email interview with Luke Allen, a psychologist specializing in gender-affirming care, April 20, 2023

Email interview with Dr. Carl Fleisher, psychiatrist and medical director at the Boston Child Study Center in Los Angeles, April 20, 2023

Email interview with Madeline Deutsch, professor and medical director of the UCSF Gender Affirming Health Program, April 19, 2023

Office of the Missouri Attorney General, "Missouri Attorney General Andrew Bailey Promulgates Emergency Regulation Targeting Gender Transition Procedures for Minors," April 13, 2023 

Office of the Missouri Attorney General, "EMERGENCY RULE Title 15 - Attorney General Chapter 17 – Gender Transition Interventions," April 13, 2023

Missouri Secretary of State, "Missouri State Rulemaking Manual April 2021" accessed April 18, 2023

Missouri Secretary of State, "Rulemaking Manual," accessed April 24, 2023 

Tweet, (archived), April 13, 2023

Office of the Missouri Attorney General, "Missouri Attorney General Andrew Bailey Announces Emergency Regulation on Gender Transition Interventions for Minors," March 20, 2023

Yale School of Public Health, "Transgender individuals at greater risk of mental health problems," August 24, 2020

Transgender Health, "Mental Health Diagnoses Among Transgender Patients in the Clinical Setting: An All-Payer Electronic Health Record Study," November 2019

Williams Institute, "Suicide Thoughts and Attempts Among Transgender Adults," September 2019

Medical News Today, "How common are mental health conditions among transgender people?," May 20, 2021 

Journal of Adolescent Health, "Minority Stress Factors Associated With Depression and Anxiety Among Transgender and Gender-Nonconforming Youth," September 18, 2018

Clinical Psychology Review, "A systematic review of social stress and mental health among transgender and gender non-conforming people in the United States," December 2018

Fenway Health, "New Study Shows Transgender People Who Receive Gender-Affirming Surgery are Significantly Less Likely to Experience Psychological Distress or Suicidal Ideation," April 28, 2021

JAMA, "Mental Health Outcomes in Transgender and Nonbinary Youths Receiving Gender-Affirming Care," February 25, 2022

UK National Health Service​​, "Gender dysphoria," accessed April 20, 2023

Cleveland Clinic, "Gender Dysphoria: What It Is, Symptoms & Management," accessed April 20, 2023

Pediatrics, "A Waitlist Intervention for Transgender Young People and Psychosocial Outcomes," August 2021

Service Social, "Suicidality among trans people in Ontario," July 29, 2013 

National Center for Transgender Equality, "USTS Executive Summary," December 2016 

NPR, "Transgender and non-binary people are up to six times more likely to have autism," January 15, 2023

The New York Times, "Bans on Transition Care for Young People Spread Across U.S.," April 15, 2023

Missouri Secretary of State, "Rulemaking Manual," accessed April 20, 2023

Lambda Legal, "Advocates Promise Legal Action in Defense of Transgender People in Missouri," April 13, 2023

Missouri Independent, "Transgender Missourians consider leaving state after AG includes adults in emergency rule," April 24, 2023

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