Ellie Bridgman spent her Thursday night shift at a local gas station in Union, Mo., planning for the day she would lose access to gender affirmation treatments as the 23-year-old transgender and non-binary years attributes to the fact that “life is worth living”.

A first-of-its-kind emergency rule introduced this week by Republican Missouri Attorney General Andrew Bailey will place many restrictions on adults and children before they can receive puberty-blocking drugs, hormones or surgeries “for the purpose of changing sex”.

Transgender rights advocates have vowed to challenge the rule in court before it takes effect on April 27. But promises of swift legal action have done little to allay the concerns of trans Missourians like Bridgman who say it may be time to flee the state.

Before gender-affirming medical treatments can be provided by physicians, the regulations require people to have experienced an “intense pattern” of documented gender dysphoria for three years and received at least 15 hourly sessions with a therapist for at least 18 months. Patients should also first be screened for autism and “social media addiction,” and any psychiatric symptoms related to mental health issues should be treated and resolved.

Some people will be allowed to maintain their prescriptions while they quickly receive the required assessments.

Bridgman, who uses the pronouns she/they, has autism and suffers from depression. She said she saw only two options: move across the country, away from all her friends and family, to a state that protects access to gender-affirming care, or accept the serious risks to her life. health that may arise from the illegal purchase of hormones online.

She went to a pharmacy on Friday afternoon to pay for all her remaining refills out of pocket.

“Imposing restrictions on transitioning for people with depression is just a way for them to prevent us from transitioning altogether,” Bridgman said. “For many trans people, dysphoria is the cause of depression. You cannot treat depression without treating the underlying dysphoria.

Before Bridgman started hormone replacement therapy last summer, she said “life had no meaning” and thoughts of suicide were racing through her head. The gender-affirming care was her “last chance in life,” she said.

The settlement comes as Republican lawmakers across the country, including in Missouri, have advanced hundreds of measures aimed at nearly every facet of transgender existence, with a particular focus on health care.

At least 13 states have enacted laws restricting or banning gender-affirming care for minors. Bills await action from the governors of Montana, North Dakota and neighboring Kansas, and nearly two dozen other states are considering legislation to restrict or ban care.

National groups advocating for LGBTQ+ rights argue that Missouri’s regulations — based on a state law against deceptive and unfair business practices — go further than most restrictions enacted elsewhere.

Three states have imposed restrictions on gender-affirming care through regulation or administrative order, but Missouri’s regulation is the only one that also limits treatment for adults.

Cathy Renna, spokesperson for the National LGBTQ Task Force, said the rule shows how Republicans are now successfully expanding the scope of gender-affirming care restrictions beyond minors, something advocates have been warning about ever since. months.

“When they see something working in one state, they’ll try to replicate it in another,” Renna warned.

Bailey’s restriction comes after a former employee of a clinic for transgender youth in St. Louis alleged that doctors at the University of Washington Transgender Center were rushing to provide treatment without proper patient assessment.

Bailey said he was investigating the clinic but had not yet released a report. The allegations of abuse were disputed by others, including another former employee and patients. Neither Bailey nor the university responded to phone and email messages seeking comment.

Dr. Meredithe McNamara, assistant professor of pediatrics specializing in adolescent medicine at the Yale School of Medicine, said the evidence broadly supports maintaining access to hormone therapy and other gender-affirming care.

As part of a consent process, Bailey’s Rule requires patients to be shown documents containing nearly two dozen specific statements raising concerns about gender-affirming treatments — a practice that doctors like McNamara have denounced as a form of conversion therapy.

“There is no evidence that shows psychotherapy as the only treatment is effective,” she said.

Stacy Cay, an autistic trans woman from Kansas City, stockpiled vials of injectable estrogen in anticipation of the restrictions. The 30-year-old actress and model realized she only needed a small dose and saved enough estrogen to last about a year. When that runs out, she’ll have to cross state lines to fill prescriptions or consider moving elsewhere.

Cay said her ongoing depression would cut off her access to hormones under regulations and her autism diagnosis could complicate her path to future care. Although the regulation does not specify whether autism disqualifies a person for gender-affirming care, it does mandate an assessment.

A 2020 study from the natural science journal Nature Communications estimated that transgender and gender-diverse people, or those whose gender expressions do not conform to gender norms, are 3 to 6 times more likely to have autism. than cisgender people. They were also more likely to have other developmental and psychiatric disorders, including depression.

“They know a lot of us have autism, and it’s part of their strategy to portray us as unstable — that we can’t be trusted to make our own medical decisions,” Cay said.

Lawyers for Lambda Legal and the American Civil Liberties Union have announced plans to challenge the new rule in court.

Missouri falls under the 8th U.S. Circuit Court of Appeals — the same court that upheld a preliminary injunction last year preventing Arkansas from enforcing a first nationwide ban on trans children receiving gender-affirming treatment. Federal judges have also blocked enforcement of a similar law in Alabama.

Republican lawmakers leading Missouri’s efforts to ban gender-affirming treatments for minors said Friday they have no plans to expand their legislation to include adults.

Separate bills passed by the Missouri House and Senate would ban treatments for children under 18, but place no restrictions on adults with private insurance or willing to pay for their own health care.

“I believe it’s detrimental to a person’s body, probably even their psyche, to undergo treatments like this,” said Sen. Mike Moon, the Senate’s lead legislation sponsor. “Adults have the opportunity to make decisions like these.”


Schoenbaum reported from Raleigh, North Carolina, and Lieb reported from Jefferson City. Associated Press editor Jeff McMillan contributed from Scranton, Pennsylvania.

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