Missouri this month became the first state in the country to severely restrict gender treatments for people of all ages, following a series of quieter moves across the country that have been chipping away at transgender adults’ access to medical care.
Last year, Florida joined six other states in banning Medicaid from covering some form of gender care for transgender people of all ages. These bans affect an estimated 38,000 beneficiaries of the public insurance program, according to the Williams Institute, a research center at U.C.L.A.’s law school.
And in at least five states, Republican legislators have proposed bills that would abolish gender care for minors as well as young adults. Some are attempting to ban it for anyone under 21, and others for those under 26.
Missouri’s sweeping new policy took a different approach. Citing consumer protection laws meant to regulate fraud, the state attorney general, Andrew Bailey, issued an emergency rule prohibiting doctors from providing gender treatments to patients — of any age — unless they adhere to a slew of significant restrictions, including 18 months of psychological assessment. The rule also said that patients should not receive gender treatments until any mental health issues are “resolved.”
The onerous restrictions amount to a “de facto ban,” said Gillian Branstetter, a communications strategist at the American Civil Liberties Union, whose Missouri chapter announced its intent to file a legal challenge to the rule.
“The political situation regarding trans people’s health care was always headed here,” Ms. Branstetter said.
The rule excludes people who are currently receiving treatments, so long as they and their doctors “promptly” comply with the psychological assessments and other restrictions.
Aro Royston, a 35-year-old transgender man in St. Louis, said he was shocked by the new policy. He said he had been taking testosterone for eight years, with monthly refills prescribed by his doctor. If he could no longer have access to the treatments, he would be “devastated,” he said, and would travel out of state to receive care.
“I think what upsets me most is, I’m a functioning member of this society,” said Mr. Royston, a program manager at a U.S. defense contractor. “I’ve worked on defense programs to protect my nation. And my nation can’t protect me?”
Missouri’s new policy goes into effect on April 27 and expires in February 2024, when the state legislature will be back in session. (Two bills that would have banned care for minors — and prohibited Medicaid from covering it for all ages — have not advanced in this year’s session.)
Although Mr. Bailey’s order applies to all ages, his public comments have focused on children, echoing the rhetoric of Republican politicians across the country and in Missouri. “As Attorney General, I will always fight to protect children because gender transition interventions are experimental,” Mr. Bailey said on Twitter.
In February, his office launched an investigation of a youth gender clinic at Washington University in St. Louis after a former employee filed a whistle-blower complaint claiming that patients there were rushed into treatment and not given adequate psychological screenings. (The clinic said that it followed the accepted standards of care.)
When asked why his order includes adults, Madeline Sieren, a spokeswoman for Mr. Bailey, said, “We have serious concerns about how children are being treated throughout the state, but we believe everyone is entitled to evidence-based medicine and adequate mental health care.”
Fourteen other states — Alabama, Arizona, Arkansas, Georgia, Idaho, Indiana, Iowa, Kentucky, Mississippi, South Dakota, Tennessee, Utah and West Virginia and, as of Wednesday, North Dakota — have passed laws restricting gender care for minors.
Although there is some debate among medical professionals about which children will benefit from gender-affirming care and when they should begin treatments, several large medical groups in the United States, including the American Academy of Pediatrics, have condemned the legislative bans.
Terry Schilling, the president of the American Principles Project, a right-wing advocacy group pushing for restrictions on transgender rights, said in an interview earlier this year that focusing on minors had been a short-term political calculation. His organization’s long-term goal, he said, was to eliminate transition care altogether.
“I view this whole issue the same as I view lobotomies or eugenics — it’s a bad medical fad,” he said.
Mr. Schilling said policies might include outright bans for people of all ages, or bills to make it easier for people to sue medical providers if they regret transitioning. He also raised the possibility of classifying transition care as “consumer fraud” — the same approach put forward by Mr. Bailey — because he contends that it is impossible to change genders.
Over many years, seven states — Arizona, Florida, Missouri, Nebraska, South Carolina, Tennessee and Texas — have enacted policies banning Medicaid from covering some type of gender-affirming care. (The federal insurance program for low-income people is partly funded by states, which also have wide latitude to determine eligibility.)
The Medicaid bans are “on shaky legal ground,” said Christy Mallory, legal director of the Williams Institute. Courts in Wisconsin and West Virginia have ruled that such bans violate the Affordable Care Act, which prohibits sex discrimination, as well as other federal rules.
But some legislators are introducing broader bills that would prohibit gender-related care at government-owned or operated health centers, or at those that accept state funding.
In Oklahoma, for example, a bill introduced this year by State Senator Nathan Dahm would withhold Medicaid reimbursement — for any procedure or treatment — from any health center that offers gender care or works with a provider who offers it.
In an interview in January, Mr. Dahm said that his only goal was to stop taxpayer money from covering transition procedures. “If an adult wants to make that decision and pay for it themselves, then they can do so,” he said. He also acknowledged, however, that the policy could spur some health care providers to stop offering care to adults.
Over the past few decades, doctors have increasingly removed barriers, such as psychological evaluations, for adults to get hormone treatments, shifting decision-making to patients themselves.
“There’s very, very broad consensus that gender-affirming care for adults is appropriate and helpful,” said Erica Anderson, a clinical psychologist and former president of the U.S. Professional Association for Transgender Health.
Dr. Anderson, a transgender woman, has publicly voiced concerns about the rising number of adolescents, especially those with complex psychiatric issues, seeking gender-related care. She has also supported the policies of certain European countries, including Sweden and Britain, that have recently limited when children can undergo certain medical treatments.
But last month, Dr. Anderson joined hundreds of clinicians in signing a letter that emphasized gender-affirming care is beneficial and important for many transgender children and denounced the legislative bans in the United States. The efforts to extend such restrictions to adults will add significant harm, she said.
“The blurring between youth and adult care is ominous,” she said. “It’s an ominous sign of overreach by people who think that the state should decide people’s personal lives.”
The Missouri rule has also received pushback among some conservatives in the state. Secretary of State Jay Ashcroft, a Republican who recently announced he was running for governor, told St. Louis public radio that although he supported bans for children, he did not believe the state should restrict care for adults.
“I don’t think people should do it,” Mr. Ashcroft said, referring to gender treatments for adults. “But there’s a difference between what I think and where I think the government should be involved.”
Maggie Astor contributed reporting.