Introduction

 The day Senate Bill 49 went into effect, I wasn’t in Missouri. I go to college out of state, you see, and instead of losing my healthcare I was attending the first lecture of my Fundamentals of Epidemiology class at Johns Hopkins University.

 

     I have been very privileged to be able to leave Missouri behind. For my own well-being as a trans and queer person, it was what I needed. And in the past few weeks, I’ve celebrated several transgender friends getting out of Missouri, seeking happier and safer futures in places with less hostile laws like Minnesota, Massachusetts, and Maryland. I’ve helped fundraise for two more people hoping to move out of Missouri by the end of the year.

 

     As a public health student, I am also keenly aware that this is bigger than myself, my friends, and my neighbors. Senate Bill 49, which went into effect in August 2023, calls forth ethical issues about gender affirming care for transgender youth.

 

     The ethical question I wish to discuss is not should transgender children be allowed the right to transition? The answer is an undeniable yes. Rather, the ethical problem arises when transphobic politicians start meddling with the bodily autonomy of transgender youth. What are the public health consequences of such political action against transgender Missourians?

 

 

Missouri’s Senate Bill 49

      For those who aren’t already familiar with Senate Bill 49, allow me to summarize. This law prohibits healthcare providers from performing gender affirming surgeries on minors or prescribing puberty blockers or hormone therapy to minors (Missouri Senate, 2023). If they do so, their license will be revoked. Additionally, gender transition surgeries are now banned for any transgender adult in a Missouri prison, and MO HealthNet cannot cover the cost of medical components of any person’s gender transition, regardless of age (Missouri Senate, 2023). Transgender adults on Medicaid in Missouri cannot use that resource to access hormone therapy or gender-affirming surgery, making such healthcare very difficult to access.

 

     Advocates for transgender rights and well-being in Missouri have objected to this legislation since it was first introduced, even filing a lawsuit to block the implementation of SB 49 after it was passed. Nora Huppert, Staff Attorney at Lambda Legal, who filed Noe v. Parson, stated the argument repeated by activists and organizations all over Missouri and throughout the United States: “SB 49 would deny adolescent transgender Missourians access to evidence-based treatment supported by the overwhelming medical consensus. This law is not just harmful and cruel; it is life-threatening” (Lambda Legal, 2023).

 

     They’re not wrong. Recent findings have shown gender-affirming healthcare to be safe and effective in improving health outcomes for transgender and gender non-conforming people. A 2022 study from the Stanford University School of Medicine, focused specifically on gender affirming hormone therapy, found that access to gender-affirming hormones improves mental health outcomes for both children and adults. When transgender patients seeking access to gender-affirming hormones begin treatment in adulthood, the Stanford study finds “an 81% decrease in adjusted odds of past-month severe psychological distress and a 21% decrease in past-year suicidal ideation.” The outcomes are even better, however, when patients start between the ages of 14 and 17. In the Stanford study, starting hormone therapy adolescence is associated with  a much more impressive “153% decrease in the adjusted odds for past-month severe psychological distress and a 62% decrease for past-year suicide ideation” (Turban et al, 2022).

 

     Now that SB 49 has gone into effect in Missouri, adolescents will be forced to wait for that treatment, even if their families and doctors have agreed that they are ready. Consequently, even if they eventually access hormones in a few years, they will have missed out on health benefits that are, for many, more life-changing in adolescence than adulthood.

 

     This is the state of transgender healthcare in Missouri today. Research and advocacy are increasingly moving into agreement, while the legislature sprints in the opposite direction.

 

Four Pillars of Medical Ethics

      I have my own opinion, shaped by my lived experience as a queer and transgender young adult who lived in Missouri from age 9 to 18, and further informed by my experience as a grassroots advocate for health equity (something my family was highly involved in even before we moved to Missouri). At this point in my writing, you can tell I oppose Missouri’s new law.

 

     Let us frame the policy issue with a separate yet related lens, however, by reviewing the four pillars of medical ethics:

 

      First, there is beneficence. Can healthcare providers use gender-affirming health care interventions such as surgeries, hormone therapy, and puberty blockers, to promote the best interests of their patients?

 

     General wisdom of the transgender and gender non-conforming community in Missouri says yes. Not every transgender or gender non-conforming person wants to pursue a medical component of gender transition when they come out, but for many, it can help reduce gender dysphoria and improve well-being.

 

     One study, published in 2022, followed up with 15 patients through a phone interview and survey four decades after their gender-affirming surgery. They concluded:

 

“Gender-affirming surgery is a durable treatment that improves overall patient well-being. High patient satisfaction, improved dysphoria, and reduced mental health comorbidities persist decades after GAS without any reported patient regret” (Park et al, 2022).

 

Of course, the small sample size of the study, and the fact that the field was still in its infancy when the participants experienced their surgeries, are important limitations. Yet, it is a promising start to research that will hopefully be repeated many times in the future, as more transgender individuals survive to old age and can report their experiences with gender-affirming surgery to interested researchers. Gender-affirming care has fulfilled the beneficence aspect of medical ethics for decades already, and it is in even higher demand today.

 

     Next, there is non-maleficence. Healthcare providers— indeed, anyone considering medical ethics, such as trans rights activists— have a moral duty to do no harm.

To this end, the World Professional Association for Transgender Health has published eight versions of Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People since 1979. The most recent version was released in 2022.

 

     Their stated goal for the standards of care is as follows:

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“to provide clinical guidance for health professionals to assist transsexual, transgender, and gender nonconforming people with safe and effective pathways to achieving lasting personal comfort with their gendered selves, in order to maximize their overall health, psychological well-being, and self-fulfillment.” (Coleman et al, 2022).

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The mere existence of these standards of care stands in opposition to Steven Ohmer’s claim that “the science and medical evidence is conflicting and unclear” when he, as circuit court judge, denied the Noe v. Parson preliminary injunction and allowed the Missouri government to go forward with implementing SB 49 (Ohmer, 2023).

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     We have existing standards to protect children (unsurprisingly, they do not include blanket bans on healthcare). Worldwide, transgender and gender non-conforming communities exist, and we seek existing health care practices that are safe and life-saving.

 

     Denial of gender-affirming healthcare is itself malicious. In the interest of non-maleficence, Missouri lawmakers should instead create laws that expand access to the best quality care for transgender patients and allow health providers to fully practice up-to-date standards of care. 

 

      The third pillar of medical ethics is autonomy, such that every patient has the ultimate decision-making responsibility for their own treatment. From heated debates over abortion to COVID-19 vaccine mandates, autonomy is the most controversial medical ethics concept in Missouri today.

This one does not require in-depth explanation. Even at the surface level, it is obvious that SB 49 violates the autonomy of transgender patients in Missouri by taking away even the options for medical components of gender transition.

 

     Every person cherishes their own autonomy, yet many politicians and even everyday people in Missouri seem to have no problem taking it away from a child dreading puberty, hoping that puberty blockers can buy them some time to figure out the best path forward as they navigate gender and changes to their mental and physical health. They see no issue with letting their own strong opinions override another adult’s desire to modify their chest, even though they’ve never met the person.

 

     The fourth pillar of medical ethics is justice. As a knowledge community passionate about medical ethics, we are concerned with how health resources are not only legalized, but also distributed equitably throughout a population.

 

     SB 49 is unjust because it restricts the bodily autonomy of transgender and gender-nonconforming people in a way that will not happen to cisgender people. It goes without saying that this makes the legislation discriminatory and transphobic.

 

     Even within the population of transgender, non-binary, and gender non-conforming Missourians, the law does not affect all transgender people equally. Transgender adults with access to wealth and resources can still access gender affirming healthcare, but the transgender people targeted specifically by this law will have to wait years until they turn 18, are released from prison, crowdfund for their expensive procedures without support from MO HealthNet, or leave the state entirely in order to access these health resources like surgery or hormone therapy. Young, incarcerated, and/or impoverished transgender Missourians face more barriers to healthcare than the more privileged members of this community. The most vulnerable people in the transgender community are targeted most by the new law.

 

Missouri’s current policy is not in Missouri’s best interest

      Here is what Missouri must not do.

 

     There should not be blanket bans of medical procedures proven to be safe, and even life-saving, for transgender individuals. The American Academy of Pediatrics (AAP), the American Medical Association, the American College of Obstetricians and Gynecologists, and the World Health Organization all “support giving transgender adolescents access to the health care they need” (Wyckoff, 2023). The AAP even voted to reaffirm their gender-affirming care policy in August 2023– mere weeks before SB 49 went into effect in Missouri– out of concern about state-level laws like this in America. Unequivocally, “The AAP opposes any laws or regulations that discriminate against transgender and gender-diverse individuals, or that interfere in the doctor-patient relationship” (Wyckoff, 2023).

 

     Yes, there are gaps in the current literature. For instance, there are very few longitudinal studies of transgender individuals who start puberty blockers in adolescence and are observed over decades (Rew et al, 2021). How can there be? Researchers would have had to anticipate the medical questions of the 2020s back in the 1980s and 1990s, which was a very different era for LGBTQ+ health as AIDS was still wiping out a generation of queer adults and puberty blockers were not FDA approved for children with precocious puberty until 1993. Now is the time to start such research, and it will be worthwhile– short-term findings of reduced suicidal thoughts are promising, and long-term research will allow individuals and families to make even more informed decisions while public health experts refine even better standards of care. If the understandable lack of longitudinal studies is concerning to lawmakers, it does not make sense to ban the procedures and shut down medical advancements. They should instead do as the AAP has done, authorizing a systematic review of the evidence with the ultimate goal of improving and expanding access to care for transgender children.

 

Recommendations

      Here is what Missouri could do.

 

     There are existing organizations in Missouri working on community building, mental health resources, and material support for transgender and gender non-conforming Missourians, and their projects could be scaled up so that they reach every vulnerable transgender person in the state who needs them.

 

     The St. Louis Queer+ Support Helpline (SQSH) was founded in 2019 by queer individuals to meet the needs of their community. Through a peer support helpline that prioritizes the health and well-being, safety, dignity, and privacy of all callers, as well as community events and projects like “Community Anthology: Dreaming Towards Liberation” published in 2023 and written by queer St. Louisans, SQSH is experimenting with creative approaches to mental health in the community and tracking their data (SQSH, 2020). Meanwhile, Transformations– an organization led by trans women of color in the Midwest– provided $7,000 in microgrants to transgender youth in 2022 (Transformations, 2022). This direct funding helped young transgender people with their medical costs, essentials like food and housing, and more. Both SQSH and Transformations are examples of successful organizations led by LGBTQ+ individuals themselves, doing their best to fill needs that the government is only worsening, not addressing.

 

     If the Missouri state government put its resources towards supporting housing (a concern in 13% of calls to the St. Louis Queer+ Support Helpline) and medical costs for transgender residents, that would make a tremendous difference (SQSH, 2020). Additionally, the state could support local projects such as gender-affirming closets, where people can affordably transition their wardrobe through clothing swaps and learn safe techniques for chest binding.

 

     Once the financial and material resources are available for transgender children and adults to live as their authentic selves without falling into poverty, a different Missouri where schools are actually encouraged to teach accurate, respectful, LGBTQ+ inclusive curriculum would empower transgender youth to come out and actually use such resources.

 

     I would prefer to live in that kind of Missouri. I will continue advocating for its possibility.

 

Conclusion

      Missouri’s Senate Bill 49 is a flawed, discriminatory law that goes against the principles of medical ethics. Banning gender-affirming healthcare for patients who are under 18, incarcerated, or enrolled in MO HealthNet has a disproportionate, negative effect on some of the most vulnerable subsets of Missouri’s transgender and gender non-conforming population.

 

     National and international health organizations support gender-affirming care for both adolescents and adults, and research is ongoing into how surgery, puberty blockers, and hormones like estrogen and testosterone can best be utilized to improve health outcomes.

 

     Missouri’s state government is moving in the wrong direction. Rather than banning gender-affirming healthcare’s best practices, they should focus on eliminating barriers to care such as cost, stigma, and the availability of clinics and telehealth.