UPDATE – May 1st, 2023, St. Louis County Circuit Judge Ellen Ribaudo granted a 14-day temporary restraining order blocking Attorney General Andrew Bailey’s emergency rule until at least May 15th following a lawsuit filed by ACLU Missouri and Lambda Legal. A hearing is scheduled for 1 PM on May 11th, which could halt enforcement of the emergency rule until after the completion of the lawsuit.

Effective April 27th, an emergency rule issued by MO Attorney General, Andrew Bailey, sets new restrictions for adults and minors seeking gender-affirming care in the state of Missouri. The emergency rule is to remain in effect until it expires on February 6th, 2024.

The emergency rule requires compliance with eleven guidelines from any person or health organization providing “Covered Gender Transition Intervention”, or simply “Intervention”, to patients. “Intervention” is defined in the emergency rule as the provision or prescription of any puberty-blocking drugs, cross-sex hormones or surgery for the purpose of transitioning gender, decreasing gender incongruence or treating gender dysphoria. “Intervention”, as defined within the document, excludes treatment for genetically or biochemically verifiable sex development disorders.

The restrictions set in place by the emergency rule require any person or health organization providing “Intervention” to (listed in order of appearance in the document):

A. Assess annually whether or not the patient continues to have gender dysphoria
B. Obtain informed consent after disclosing 23 specific risks (p. 3-5)
C. Ensure that the patient has exhibited a medically documented, long-lasting, persistent and intense pattern of gender dysphoria for at least the 3 most recent consecutive years
D. Ensure that the patient has received a full psychological or psychiatric assessment, consisting of at least 15 separate hourly sessions over the course of at least 18 months, with a single provider conducting at least 10 of the sessions
E. Ensure that any psychiatric symptoms from existing mental health comorbidities of the patient have been treated and resolved
F. Ensure that the patient has received a comprehensive screening to determine whether or not they have autism (It is unclear whether or not autism is a disqualifying condition. Footnote 34 suggests that, if allowed at all, rehabilitative interventions to address the patient’s autism must occur before providing gender-affirming care. At this time, The Attorney General’s Office has not responded to my inquiry into clarification on the matter.)
G. Ensure, in the case of a patient who is a minor, that the patient has received and will continue to receive, at minimum, an annual comprehensive screening for social media addiction or compulsion and that the patient has not suffered from either for at least six months prior to beginning any intervention
H. Ensure on at least an annual basis that the patient is not experiencing social contagion with respect to their gender identity
I. Adopt and follow a procedure for all patients to track all adverse effects, both expected and unexpected, that arise from any course of intervention for at least fifteen years
J. Maintain data about adverse effects in a form that can be accessed readily for systematic study
K. Keep informed written consent on file either from the patient or from all parents or guardians who have the authority to provide consent in the case of minors – Consent must be renewed quarterly for the first 3 years and then at least twice a year afterward.

The emergency rule is the first of its kind, most notably because the guidelines have not been passed by a legislator or signed by a governor but, rather, are a result of Attorney General Andrew Bailey’s power to enforce consumer protection laws. Bailey cited Missouri’s Merchandising Practices Act, which is typically used to prosecute fraudulent business practices, as reason to enforce new guidelines on providing gender-affirming care. 

Bailey defended the emergency bill in an interview with St. Louis Public Radio, stating the guidelines are “intended to protect all patients and make sure that all patients have access to mental health services.” The American Medical Association stated in a press release that this kind of care is already tested, describing gender-affirming care as “medically-necessary, evidence-based care that improves the physical and mental health of transgender and gender-diverse people.”

Lambda Legal and the American Civil Liberties Union of Missouri issued a joint statement describing the rule as “a shocking attempt to exploit Missouri’s consumer protection laws in order to play politics with life-saving medical care.” They additionally asserted that “the Attorney General’s so-called emergency rule is based on distorted, misleading, and debunked claims and ignores the overwhelming body of scientific and medical evidence supporting this care as well as the medical experts and doctors who work with transgender people every day.” 

In only the first few months of 2023 alone, the ACLU has tracked 469 anti-LGBT+ bills at the time of writing this article. Missouri is responsible for 48 of these, falling short in quantity only to Texas at 52 bills. The passing of anti-LGBT+ bills in 2023 is an exponential increase from the 278 bills tracked by the ACLU  in all of 2022.

Anti-trans legislation has especially been on the rise with 19 anti-trans bills introduced in state houses in 2018, 25 bills introduced in 2019, 60 bills introduced in 2020, 131 bills introduced in 2021 and 155 bills introduced by October of 2022. 

Those who wish to stand with the trans community and push back against the emergency rule can donate to the American Civil Liberties Union of Missouri and Lambda Legal to help challenge the actions of Attorney General Andrew Bailey. LGBT+ supporters can also donate to the general ACLU fund or to The Trevor Project to help combat the broader wave of anti-LGBT+ legislation. 

For further action, individuals can also plan a peaceful protest after learning about their rights as protestors, contact local representatives to voice concerns, contact the Missouri Attorney General’s Office directly, vote for political candidates who advocate for LGBT+ rights in the upcoming election or get involved locally by volunteering at community sites such as The Center Project.  

Those who live in safe states (3 or less anti-LGBT+ bills tracked by the ACLU) can also provide asylum or offer transportation through A Place for Marsha to trans adults fleeing hostile states (10 bills or more).