A Missouri judge upheld the state’s ban on gender-affirming care for minors Monday, a victory for opponents of the practice in a continuing nationwide battle over transgender issues.
The 2023 law known as Senate Bill 49 prohibits the use of puberty blockers, cross-sex hormones and surgery in people under the age of 18 to treat gender dysphoria, defined by the American Psychiatric Association as the “psychological distress that results from an incongruence between one’s sex assigned at birth and one’s gender identity.” An exception is made for children who were already receiving treatment prior to August 2023.
“We are the first state in the nation to successfully defend such a law at the trial court level,” Missouri Attorney General Andrew Bailey said in a statement Monday.
The judge’s decision to uphold the ban followed a nine-day trial in a lawsuit filed by three transgender children and their parents.
“The medical dispute has become more fractured in the last year, with even more medical authorities questioning the evidence for these interventions,” Wright County Circuit Judge R. Craig Carter wrote in his 74-page ruling.
Gender-affirming care is highly individualized, and some people may decide to use reversible puberty suppression therapy, including hormone therapy that can lead to gender-affirming physical change. Surgical interventions, however, are not typically done on children and many health care providers do not offer them to minors.
The use of gender-affirming therapy in minors is more controversial than in adults, but the Endocrine Society – whose guidelines Carter cited repeatedly in his opinion – has strongly opposed bans on gender-affirming care for minors. The society sets guidelines that help medical professionals determine the best practices to provide appropriate care for people who are transgender and gender-diverse.
“This ruling sends a chilling message that, for some, compassion and equal access to health care are still out of reach,” said Lambda Legal and the ACLU of Missouri, which have been providing legal counsel to the plaintiffs. The organizations say they will appeal Monday’s ruling.
Doctors who defy the law could have their licenses to practice medicine in Missouri revoked and could also be sued by patients up to 15 years after receiving treatment.
The law also prohibits state Medicaid funds from being used to pay for gender-affirming care for a patient of any age.
Nationwide fight over transgender treatment
The ruling refers to “substantial medical dispute about the causes and treatments of gender dysphoria.” Dozens of major medical groups – including the American Medical Association – say treatment for gender dysphoria is “medically necessary” and should be “determined by shared decision making between the patient and physician.” The American Academy of Pediatrics also supports access to gender-affirming care.
The judge in his ruling cited a report by the National Health Service in the UK that “concluded that the interventions at issue in this lawsuit rest on ‘remarkably weak evidence’ and that there is ‘no good evidence on the long-term outcomes of interventions.’”
In the ruling the judge also noted the World Health Organization’s decision not to “craft guidelines for treating gender dysphoria in adolescents because ‘the evidence base for children and adolescents is limited and variable.’”
A majority of states now have bans similar to Missouri’s in place, Carter’s ruling noted, and there are multiple challenges to those laws now under appeal.
Monday’s decision in Missouri came just a week before the US Supreme Court is scheduled to hear oral arguments in a challenge to a similar law in Tennessee. In that case, a 15-year-old transgender girl and her parents say the child’s mental wellbeing is at stake.
“I don’t even want to think about having to go back to the dark place I was in before I was able to come out and access the care that my doctors have prescribed for me,” the 15-year-old said in a statement released by the ACLU.