When Missouri Attorney General Andrew Bailey announced an emergency order to restrict gender-affirming care for minors and adults on April 13, AJ Hackworth sent an email to his provider in Springfield to ask about his testosterone prescription.
The next day his doctor at CoxHealth told him she would no longer be able to fill prescriptions for hormone replacement therapy.
“I do not currently have the processes in place to defend my license to practice gender affirming care should the state investigate me under the new Attorney General emergency rule,” she wrote on April 14.
Under the emergency order, which goes into effect on Thursday and runs through February 2024, patients of all ages would have to meet a long list of requirements to prove that they are fit to start or continue gender-affirming care. Even if they’re legally adults, even if they’ve already been accessing this medically necessary healthcare for years, advocates and trans Missourians told BuzzFeed News that the requirements are burdensome, vague, and overly broad. Some fear it will effectively end gender-affirming care in the state entirely — and it’s already causing problems for the people who can least afford to find care elsewhere.
Transgender people will have to partake in 15 hourlong therapy sessions over the course of 18 months and prove that any mental health issues — such as anxiety and depression — are resolved prior to receiving treatment for gender dysphoria under the order. The rule also requires patients to have three years’ worth of medical documentation of gender dysphoria and receive a screening for autism, and will force providers to maintain a database of “adverse effects” of gender-affirming care for at least 15 years.
Hackworth, a 34-year-old father of two, said the state’s anti-trans bills and Bailey’s probe into trans health clinics made him fear a moment like this would come and pushed him to prepare for a possible future where his access to hormones was taken away. Out of precaution, he began rationing a portion of testosterone from his monthly vials and has stockpiled half a year's worth of hormones. (If unopened, testosterone has a shelf life of around a year and a half.)
“It’s kind of always been in the back of my mind that something like this is probably going to happen,” he told BuzzFeed News.
The ACLU of Missouri and Lambda Legal filed a suit on Monday on behalf of two families of young trans people to get a temporary restraining order to block the order from taking effect.
“This unprecedented attempt to use Missouri’s consumer protection law to go after necessary and often life-saving healthcare must be stopped. We are honored to stand alongside our courageous plaintiffs in challenging this dangerous and harmful policy. We will defend the rights of transgender people and ensure access to necessary, evidence-based medical care,” Nora Huppert, a staff attorney at Lambda Legal, said in a statement.
But hundreds of trans people across the state are still anxiously trying to sort out how to continue receiving gender-affirming care, either in Missouri or a neighboring state. Some are considering moving.
As Hackworth’s provider at CoxHealth worked to figure out how to get documentation about his medical history ready to comply with the order, she urged him to get a 90-day supply of hormones to hold him over.
However, the process of actually obtaining a three-month supply of hormones can be difficult — especially for patients taking testosterone, which is considered a controlled substance by the federal government.
Since Medicaid only covers his testosterone on a monthly basis, Hackworth had to crowdfund to pay for the extra vials out of pocket. Then his pharmacy said he needed a handwritten doctor’s note to explain the bulk prescription. His refill still hasn’t been filled.
In Branson, 28-year-old Torin, who asked to be identified by their first name to protect their privacy, was also told by CoxHealth that they couldn’t get their prescription filled on April 14. As of last week, their provider said she would be able to continue prescribing hormones to patients as long as they are “compliant” with the order. But Torin, a parent who has a disability that prevents them from working, said they’re waiting on a letter from a psychiatrist and not sure what other documentation they might need.
“If things keep going the way they are, we're going to have to move closer to Springfield... Even that is difficult to do when you're a disabled person, you're on one income, you've got two kids, both of which are special needs,” Torin told BuzzFeed News. “It sucks, because I really don't want to consider leaving Missouri. All of our family is here. I've lived here my whole life. This is my home, but in the next 10 years if things keep going this way, then I'll probably end up leaving.”
Torin worries about the growing anti-trans climate in their town. When Bailey released a tip line for residents to share concerns about gender-affirming care in the state, Torin wondered if their neighbors would sic child protective services on their kids or if they should stop taking hormones altogether to protect themself and their family. (The site has since been taken down after Gen Z’ers spammed it with memes.)
“I wish people understood that we just want to be able to live our lives. We have as much right to live here as anyone else does,” they said.
For healthcare providers in the state, preparing for the restrictions on gender-affirming care is a flashback to the last days of abortion, which Missouri completely banned last June.
Dr. Colleen McNicholas, the chief medical officer at Planned Parenthood of the St. Louis Region and Southwest Missouri, said the organization has established care with dozens of new patients, with pop-up clinics in St. Louis, Springfield, and across the Illinois border in Fairview Heights.
McNicholas said that on April 17 alone, Planned Parenthood saw 50 new patients and added 200 new appointment slots across its nine healthcare centers in the state. Patients can schedule additional appointments online or over the phone at those health centers.
She cautioned that these restrictions will disproportionately affect Black and brown trans people and those in rural areas. “Building back access and equitable health care for folks really needs to center the people who are most impacted and the most marginalized,” she said.
The order mirrors the same tactics Missouri has used to eliminate access to abortion, but McNicholas said she was still surprised by how quickly Bailey was able to set the new restrictions into motion — and how this threatens smaller healthcare organizations that lack the resources and capacity to fight back.
“This tactic of increasing administrative burden so substantially and pairing that with the reality that the language in this rule is so devoid of scientific understanding of how we actually practice medicine … makes it very difficult for individual providers to feel comfortable and confident with how they can comply with the rule and provide good quality care to patients,” McNicholas said.
Many of the Planned Parenthood appointments were booked within the first few hours, and Stevie Miller, an uninsured nonbinary trans person living in rural Howell County, was able to snag a slot.
The 33-year-old who drives for DoorDash was planning to start hormones after he’d paid off his car later this fall. But as soon as he heard about the emergency order, Miller knew he needed to get a prescription on the books no matter what.
Last Wednesday, after crowdfunding for his prescription, Miller drove 100 miles, about two hours from his small town, to the Springfield Planned Parenthood. By that evening, he was able to take his first shot, which he filmed and posted on TikTok.
“I was so anxious Wednesday, and honestly after the shot I felt so much lighter. I still have the anxiety but it doesn’t feel as crippling,” he said. “That’s the only real thing that is feeling different right now, and it feels good.”
Devyn Taylor, a 34-year-old trans woman living in Springfield, is also waiting for her insurance to approve a 90-day supply of estrogen and gathering the documentation to allow her continued hormone replacement therapy, even though she’s been receiving care for a decade. Because of past surgeries, her body no longer produces its own hormones and she fears she could go into early menopause or develop osteoporosis if her prescription is denied.
She wishes she could stay focused on the life she’s built in Missouri: her part-time DJ gigs and the garden she hopes to set up with her partner. But instead, the order has forced her to consider the feasibility of staying in the state, or even in the US.
“This takes up a lot of mental and emotional real estate. It’d be nice to just live somewhere and not worry about the potential of needing to leave,” she told BuzzFeed News. “It’s hard when you feel like on the immediate horizon you might have to pick up everything and go somewhere. I look forward to that stability if I could just get past this, but I don’t see an easy route to that.”