I have decided that if this whole lawyer gig doesn’t work out I am going to become the commissioner of the National Hockey League. Have I ever played hockey? No. Have I ever watched a hockey game? No. Does all of my hockey knowledge come from GIFs of the famed Philadelphia Flyers mascot Gritty? Absolutely yes. By all means, I am wholly unqualified for the job. I do have the same degree as Missouri Attorney General Andrew Bailey, though, and while he is as unqualified to make major medical decisions for thousands of Missourians as I am to run a major national sports league, he has gone ahead and done just that.
New emergency rules governing how and when health care providers in Missouri could administer gender-affirming care to minors and adults were set to go into effect on April 27 and last until February 2024, presumably in order to give the legislature time to codify the ban. This was a unilateral action by the attorney general, who claimed he can issue such a broad rule because the standard treatments for gender dysphoria are not approved by the Food and Drug Administration and are therefore “experimental,” despite “off-label” usage of medications being standard practice across large parts of the medical field.
These new restrictions are beyond extreme, requiring:
- At least three years of medically documented intense and persistent gender dysphoria.
- At least 15 hours of therapy over the course of 18 months, during which all other possible reasons for a patient experiencing dysphoria must be investigated.
- A new informed consent form that describes hormone replacement therapy and gender-affirming surgery as “experimental” and contains statements about gender-affirming care that have either been debunked or taken out of their proper context.
- Screening for autism, addiction to social media and “signs of social contagion.”
- That “any psychiatric symptoms from existing mental health comorbidities of the patient have been treated and resolved.”
- That health care providers annually reevaluate patients for gender dysphoria and renew their informed consent forms every three months.
Thanks to the intervention of Lambda Legal and the Missouri ACLU, a judge has temporarily blocked the rules from going into effect until at least May 1. The new restrictions are extremely broad, and it’s worth taking the time and effort to break them down, piece by piece, to truly understand the impact of what the attorney general is trying to do, and what these rules actually mean for trans Missourians.
Gender dysphoria, the term used to describe the distress that many transgender and nonbinary people feel as a result of the incongruence between their assigned gender at birth and their actual gender, is an incredibly complex, dynamic condition. For some people, it comes in strong, debilitating waves followed by periods of lesser distress or none at all. For others it’s like a low level buzzing in the back of their minds. For even more people, it’s something completely different. There are as many ways to experience dysphoria as there are people in the world. To limit access to gender-affirming care to only the most severe cases alone is cruel — after all, we don’t limit access to medications like antidepressants to only the most severely suffering patients — but to also require those patients suffering most to have to do so for three long years is unspeakable.
Furthermore, some transgender people may not experience dysphoria at all, for example having the knowledge that their gender identity differs from the one assigned at birth but not experiencing distress and anxiety from it. They are equally as valid and have every right to maintain their bodily autonomy and access health care that allows them to safely exist and feel the most like themselves.
These treatments are not exclusive to trans people. Hormones and surgery are used by cisgender people to affirm their gender all the time. Cisgender women with Polycystic Ovarian Syndrome are often prescribed the testosterone-blocking medication spironolactone in order to combat symptoms like excess body hair, something that in many cultures is considered decidedly unfeminine and can cause genuine distress. Spironolactone is also prescribed to transgender women in order to allow estrogen to work. Cisgender men with low testosterone levels get prescribed testosterone shots or gel to combat depression and lowered sexual function, just as transgender men are prescribed testosterone. Cisgender women frequently affirm their gender through breast augmentation, cisgender men through hair transplants. Yet the Missouri rules don’t limit affirming care for cisgender people to only the most extreme cases after a three-year waiting period. If these treatments are so dangerous and “experimental” that it requires the attorney general to circumvent democracy and standard medical practice, why are they only dangerous for one small portion of the population?
The mental health requirements are also far beyond the accepted standard of care as outlined by many mainstream medical organizations, including the American Medical Association, the American Psychiatric Association and the American Psychological Association.
Yes, talk therapy is typically a key part of the transition process, and most often the first step for any transgender person seeking to transition, both in the social and medical senses of the word. It is also true that a large number of health care providers will not prescribe hormone replacement therapy or sign off on surgeries until a patient has spoken with a therapist who will also sign off on it. I myself worked closely with my therapist, psychiatrist and primary care physician while determining if HRT was the best choice for me, and continue to do so years after starting it. This is especially true for hormones, and for good reason. Going on these medications is like experiencing puberty for a second time. It can come with mood swings, new or exacerbated mental health conditions, and all of the other fun experiences we remember from our teenage years. Ensuring a person has the coping skills and support system to handle those types of changes is extremely important and should be discussed more openly. But this is not the goal of the Missouri rule.
The Missouri rule is intended to essentially require therapists to engage in conversion therapy and commit malpractice by ignoring the standard of care, which is to treat trans people in an affirming manner. This rule, however, requires that they “explore the developmental influences on the patient’s current gender identity and to determine, among other things, whether the person has any mental health comorbidities,” meaning therapists are being asked to find literally any other possible reason someone might not identify with their assigned gender at birth, and gaslight patients before beginning to treat them in an affirming manner. This part of the restriction, as well as the requirement that all psychiatric symptoms from comorbid conditions be resolved before patients may receive gender-affirming care is so wildly outside of the bounds of reality that it outright makes it impossible for all but an extremely small number of trans people to access care.
Many transgender people live with a wide variety of mental health conditions. Sometimes this is due to trans specific issues like gender dysphoria, familial rejection, religious trauma, social stigma surrounding being trans, or discrimination and violence that they may have directly faced. Other times it has nothing to do with being trans. There are a ton of factors that lead to people being diagnosed with mental health conditions. Sometimes it’s environmental. Sometimes it’s due to a specific incident or series of incidents. Sometimes it’s genetic, or even completely random. Usually it’s a combination of all of the above. Mental illnesses are not unique to trans people, nor are they somehow different when someone also has gender dysphoria on their chart. The vast majority of mental health conditions never get completely resolved, and instead require lifelong care and management, and that’s OK! Yet for some reason Bailey seems to think that only those people who can meet this impossible standard deserve to have their gender affirmed by their health care providers.
This, of course, is still not enough for Bailey. The restrictions require that patients seeking gender-affirming care also be screened for autism, social media addiction and signs of “social contagion” before they’re allowed to receive gender-affirming care (the implication being that if a health care provider believes that any of these apply to a patient, they will be barred from receiving care).
There is some evidence that autistic people experience gender dysphoria at a higher rate than nonautistic people, but that does not make the identities of autistic trans people any less valid. Anyone who has taken a social science course will also tell you that correlation does not equal causation. This requirement almost certainly comes from anti-trans activists who claim that autistic people, especially those assigned female at birth, are somehow being manipulated by the non-autistic trans community. The assumption that autistic people are all incapable of making health care decisions is pervasive, and relies on ableist stereotypes. The infantilization of autistic trans people and the weaponization of ableism and misogyny generally in the anti-trans religious crusade could be a blog in and of itself, so I will only point out here that this is the exact same rhetoric we have seen time and time again from those that oppose gender-affirming care for minors as well.
While the general mental health issues and the autism connection are extremely complicated and hard to boil down into a digestible format, the screenings for social media addiction and “social contagion” are exceedingly simple to explain. In a few short words: If someone knows other trans people, they won’t be able to receive care.
Anti-transgender activists have somehow come to the conclusion that the fact that trans people follow each other on social media and that sometimes trans kids in the same friend group come out around the same time is some kind of proof that being trans is simply a fad or a trend that people do to seem cool and special. Putting aside for a moment the fact that people we would refer to as trans in a modern, Western context have existed since humans developed a concept of gender, this argument makes literally zero sense. People are naturally drawn to other people who have similar life experiences. Even on a subconscious level, queer people tend to find each other. There’s a running joke that a lot of people will look at their Facebook feed 10 years after graduating high school to find that their entire lunch table has come out since then. While there are sometimes cases where someone in a friend group who comes out as trans later decides that actually they aren’t, that doesn’t mean literally anyone who has trans friends and then comes out as trans themselves is doing so because of peer pressure. Not to mention the fact that one of the most beautiful things about gender and the human experience is that for many people, it’s fluid and changes throughout their lives.
I follow other trans people on social media for the same reason I follow other lawyers and Dungeons and Dragons aficionados: the things they post are of interest to me. I have a lot of trans friends in my offline life as well, but I also have a lot of friends who did marching band in college and love Jimmy Buffett. If being trans is a form of “social contagion,” so is literally everything that brings people together. It’s also worth noting that the rule requires that patients be rescreened annually for social media addiction and “social contagion” on an annual basis, meaning that even if a person doesn’t have trans people in their life when they begin to receive care, they could be cut off from care if their provider learns that they do later on.
You might be thinking that this blog entry is starting to get lengthy, and you’d be right, yet somehow there is still more to unpack.
Those unique few who manage to pass all of those tests and prove themselves worthy of receiving health care must face one final trial: not being scared off by a confusing and medically inaccurate informed consent form specifically designed to discourage them from going through with their decision to transition. This form cites to a wide variety of studies that have been cherry- picked and decontextualized for the explicit purpose of scaremongering. In the published version of the rule, Bailey points to previous statements by the World Professional Association for Transgender Healthcare (WPATH) that psychotherapy should be a part of the transition process and that lean on its reputation as a well-respected organization to support the idea that people need to be heavily restricted from receiving gender affirming care. WPATH’s official statement on the rule, however, makes it clear that it is no ally to his cause:
Attorney General Bailey’s claims were either taken out of context, cherry-picked, or from unverified sources. In some situations, the excerpted statements used in the regulation are later contradicted in the same study or article from which they were pulled. The resulting regulation from the AG’s office strings together non sequitur misinformation in their attempt to prohibit safe and legal health care.
These informed consent forms must be re-signed every three months for the first three years of care, creating a massive logistical barrier for both patients and providers that does not exist for any other form of health care.
The barriers created by the Missouri rule are so great that health care professionals who have been providing gender-affirming care feel that they will no longer be able to legally do so. Even with the exception for people who are already receiving care, the scrutiny and confusion this will create for doctors and their staff is so immense that many will have no choice but to cease providing care whatsoever.
If creating intense health care restrictions that contradict both science and democracy sounds familiar to you, that’s because it should.
This is the exact political playbook that religious extremists have been using to limit access to reproductive health care for decades, and for the exact same reasons. The idea that people can have the bodily autonomy and individual freedom to make health care decisions that allow them to live outside of strictly defined binary gender roles decimates their world view. Abortion and contraceptives have made it possible for women to have happy and fulfilling lives outside of the home, so religious leaders can no longer “definitively” point to the economic consequences of not entering a heterosexual marriage in order to scare the girls and women in their congregations into compliance. Similarly, the rise in acceptance of trans people and increased access to the health care that improves our quality of life and happiness, allowing us to live complete and fulfilled lives as our authentic selves, means that these same leaders cannot point to our suffering as “definitive” proof that their god is punishing trans people for our “sins.”
This has never been about protecting children. This has never been about ensuring people have all the information necessary to make proper health care decisions. This is about control and the enforcement of a specific religious worldview onto all Americans. Trans people have been saying from the beginning that this was never going to stop with bans on gender-affirming care for minors. And this trans person is saying that they will not stop when they are through with us.
It is a terrifying time to be transgender in this country. If you or someone you love is struggling with your mental health in the wake of the never ending never ending attacks on trans existence, please contact the National Suicide Prevention Lifeline, The Trevor Project, or the LGBT National Help Center.
