Missouri judge upholds state ban on transgender health care for minors

The state’s restrictions on gender-affirming care, passed by state lawmakers in 2023, not only bar minors from beginning cross-sex hormones and puberty blockers and undergoing gender transition surgeries. It also blocks the state from paying for gender-affirming care for adults through Missouri Medicaid and care in state prisons.

Many providers in Missouri have ceased offering gender-affirming care for minors, including patients that had begun prescriptions prior to the law’s effective date.

Plaintiffs in the case — which include gender-affirming health care providers, transgender minors and their families — had the burden to prove the statute “clearly and undoubtedly violates a constitutional provision,” the judge wrote. And because plaintiffs challenged the law in its entirety, they had to prove that there is “no set of circumstances under which the provisions would be valid.”

Carter determined the challenge did not clear the high bar on multiple arguments, but the overarching debate looked at medical consensus on gender-affirming care.

His ruling focuses on a U.S. Supreme Court precedent that allows lawmakers broad discretion in areas “fraught with medical and scientific uncertainty.” Carter concluded that there is “an almost total lack of consensus as to the medical ethics of adolescent gender dysphoria treatment,” granting the state legislature authority to ban the care.

“Regarding the ethics of adolescent gender-affirming treatment, it would seem that the medical profession stands in the middle of an ethical minefield, with scant evidence to lead it out.” he wrote.

During the nine-day trial, which took place at the end of September, experts on both sides opined on the availability of scientific research on gender-affirming care. Carter notes that plaintiffs agreed that standards of care were based on scientifically low-quality evidence. Expert witnesses for plaintiffs said during trial they still felt there was enough to justify the area of treatment.

The witnesses at trial varied in credibility, with some of the state’s experts discussing research that had been retracted. Solicitor General Joshua Divine, representing the state and defending the law, argued that the scientific community had only dismissed his experts’ findings because of “cancel culture.”

Carter’s judgment does not cite the state’s most controversial expert but does rely on the testimony of Jamie Reed, who was permitted as a fact witness instead of an expert on the topic. Reed was called to testify in order to establish facts on gender-affirming care in Missouri.

Reed, whose public affidavit in February 2023 inspired the passage of the restrictions, testified that Washington University Transgender Center at St. Louis Children’s Hospital treated many patients with mental health problems without comprehensive psychological evaluations.

There was disagreement during the trial over whether treatment from a licensed therapist was enough to warrant gender-affirming medical care or if a psychologist or psychiatrist should be a requirement.

Plaintiffs did not have a witness from the Transgender Center, apart from patient testimonies, so Carter concluded that Reed’s testimony was unrebutted.

Importantly, he also found Reed credible.

“Her testimony does not arise from any ideological or other bias,” Carter wrote. “In fact, she is married to a transgender individual.”

Reed is the executive director of a small advocacy group called the LGBT Courage Coalition, which opposes gender-affirming care for minors. Her partner is stopping testosterone treatments and “detransitioning,” an article published the day before Reed’s testimony announced.

In contrast to his views on the state’s witnesses, Carter wrote he “has concerns with deferring to the organizations relied on by plaintiffs, such as WPATH, which self-describes itself as an organization ‘committed to advocacy.’” 

WPATH, which stands for the World Professional Association for Transgender Health, is a professional organization that sets standards for gender-affirming care. During the trial, the state questioned whether WPATH was stifling research with outcomes contrary to its worldview.

Apart from these concerns, Carter said three witnesses were particularly compelling: Chloe Cole, a young woman who transitioned as a minor in California and since stopped treatment and has spoken publicly about her regrets, along with bioethicist Farr Curlin and plastic surgeon Patrick Lappert, both who emphasized potential side effects of gender-affirming care.

Because the risks were high for gender-affirming care, the treatment couldn’t be compared to experimental treatments with few known side effects, Carter wrote, and allowing teenagers to opt into an experimental treatment is dubious.

“If we don’t let a 16-year-old buy a six pack of beer and a pack of smokes, or let an adult buy those items for them, should we allow the same kid/parent team to decide to change a teenager’s sex forever?” Carter wrote in his ruling.

The ACLU of Missouri and Lambda Legal said in an emailed statement that the judgment mirrored the state’s brief, and a transcript of the trial has yet to be completed.

“The court’s findings signal a troubling acceptance of discrimination, ignore an extensive trial record and the voices of transgender Missourians and those who care for them, and deny transgender adolescents and Medicaid beneficiaries from their right to access to evidence-based, effective, and often life-saving medical care,” the legal organizations said in a joint statement.

Missouri Attorney General Andrew Bailey said in a social media post that “the national mood on this issue has moved significantly since we launched our investigation.”

“The state has a role to play,” he said, “to determine what systems need to be in place to protect kids and ensure that the adults and patients understand the lack of science and medicine behind certain recommended procedures.”