With Missouri on the brink of becoming the first state to implement sweeping restrictions on gender-affirming care for adults, transgender people and doctors in the state are warning that discarding years of established health care practices will put patients' lives at risk.
“At this point, I'm terrified,” said Axel Pollack, 24, who began his own gender-affirming care in September through a Washington University gender clinic in Creve Coeur.
Like other trans people in Missouri, the future of Pollack’s healthcare was thrown into question April 13, when Attorney General Andrew Bailey issued a temporary emergency order that would place new restrictions on gender-affirming care beginning Thursday.
The restrictions apply to people of all ages — which surprised health providers and patients because Bailey’s office last month framed the move as a tool to “protect children.” Although numerous states have sought to restrict transgender health care for minors, Missouri appears poised to be the first state to enact restrictions on such care for adults.
“The clinic is telling me that, at the moment, they don't know how this is going to affect their program,” Pollack said. “They said that I still have my appointment scheduled, but it might be best to prepare to get a new doctor in Illinois.”
To be eligible for treatment under the new emergency rules, trans people have to demonstrate multiple years of medical and mental health care history, including experiencing gender dysphoria for three consecutive years. Patients have criticized other provisions in the rules, saying they’re confusing or downright impossible to follow. Another part of the rules mandates that trans people prove that their gender identity is not being influenced by other people or a “social contagion.”
Those requirements are leading to widespread confusion for people like AJ Hackworth. A Springfield resident and father of two, Hackworth, 34, received an email on April 14 from his doctor at CoxHealth, the very day after Bailey unveiled the new rules.
The email from Hackworth’s doctor said that because of the new rules, Hackworth could no longer be prescribed gender-affirming hormones after April 27. Two days after that email, the doctor sent another. Hackworth’s care would not be interrupted, the doctor wrote — just as long as he complied with the attorney general's rules.
But Hackworth says he doesn’t know how to comply with those rules. What sort of evidence does he need to show his transition wasn’t influenced by a social contagion? Will he have to restart therapy, or find a new psychiatrist?
His doctor has no answers.
“The provider is saying that she will do everything she can to continue care, and that she is there for us, but it doesn't feel like anything is really changing,” Hackworth said. “I don't know what to anticipate. I don't know what kind of paperwork she's going to require. There's just so much up in the air. I don't know what my future looks like.”
The stakes are high for trans people waiting to find out whether Missouri will allow them to continue their treatments. But, at least right now, providers have little guidance to offer them.
At Southampton Healthcare in St. Louis, Dr. Sam Tochtrop is trying to schedule as many patients as he can before the rules go into effect. He said he’s fielding calls from patients terrified that they will lose their healthcare.
“I probably had four or five patients, and they said ‘Hey, how much of my prescription can I get at one time, because I need to keep a stock of that so I can move out of the state.’”
Dr. Colleen McNicholas, chief medical officer of Planned Parenthood of the St. Louis Region and Southwest Missouri, said that the aftermath of Bailey’s announcement has confused and worried providers and patients "now scrambling to figure out how they are going to continue this basic lifesaving care."
In facilities in St. Louis and across Missouri, Planned Parenthood opened hundreds of appointments to meet the sudden flood of patients seeking to obtain longer prescriptions for their needed medications. Others are desperate to simply become patients before April 27.
“Many of these patients have spent a lifetime overcoming barriers trying to access this health care in a way that helps them live healthy, fulfilling lives,” McNicholas said. “And many of them are asking now, first of all, why are they being targeted?”
One patient, Matty Manshack, came to Planned Parenthood's walk-in clinic for transgender people earlier this month in the Central West End. Manshack has been in recovery for addiction and was finally considering taking testosterone when he heard about Missouri’s emergency rule. He knew he needed to get an appointment as fast as he could.
“It’s a very powerless feeling to know that your health and your mental health is in someone else's hands,” he said. “People are scared of what they don't know, and what they don't understand… And not only that, but they're not willing to try and understand, which is even scarier.”
The complications are deeper than just medical appointments or vague provisions in the rules. For a trans person, losing access to hormones and gender affirming care can be life-threatening.
“This is life and death for many people,” said Michaela Joy Kraemer, the executive director of the Metro Trans Umbrella Group in St. Louis. “And to know very close friends and community members who have died by suicide recently as a result of lack of support, lack of access — it’s crushing.”
On Monday, a coalition of civil rights groups, including the ACLU of Missouri and Lambda Legal, filed a legal challenge against the emergency rules. A judge in St. Louis County will preside over a hearing Wednesday about whether to issue a temporary restraining order before the rules go into effect this week. (Southampton Healthcare in St. Louis, which employs Dr. Sam Tochtrop, is a plaintiff in the suit.)
Seeking to halt the rules from going into effect, the lawsuit argues that Bailey is overstepping his authority as attorney general to pass “unprecedented and unique restrictions so onerous that it effectively prohibits the provision of this necessary, safe, and effective care for many, if not most, transgender people in Missouri.”
Along with the lawsuit, the impending rules have sparked multiple protests across the state. Earlier this month, Pollock, the college student who receives gender-affirming care from Washington University, joined hundreds of people marching through downtown St. Louis earlier this month to protest the new rules.
“I'm more scared for myself, about the mental health aspect with my gender dysphoria,” he said. “If I have to stop taking my testosterone… my mental health is going to plummet really bad. And I'm gonna wind up in a constant depressed state, worrying about being suicidal all the time, because I can't live with who I was.”
Pollock said it was powerful to see the large turnout at the protest, and to join the crowds as they marched to St. Louis City Hall.
“It reminded me that I am not alone in this battle,” he said. “We're just a giant family who've got each other's backs. And as long as one of us keeps fighting, there's hope.”
Correction: A previous version of this report misidentified where Alex Pollack received gender-affirming care. He went to a Washington University clinic in Creve Coeur.
