Sera Hart-Smith and her partner Kyle Kiera Hart are packing their belongings to leave Missouri before Hart-Smith runs out of her supply of estrogen.

Hart-Smith has been taking estrogen since she was 19, and the couple is afraid state leaders may take that access away and push her back into the depression that she felt before medically transitioning.

“Once my body was functioning on estrogen instead of testosterone, I got so much better,” Hart-Smith said. “So the idea of that being taken away or having to go back into the pit that I lived in for the first 19 years is horrifying.”

An emergency order by Attorney General Andrew Bailey, which is scheduled to go into effect Thursday, will stop new patients from receiving gender-affirming care unless they pass multiple screenings and have three years of documented gender dysphoria.

Hart-Smith has begun her medication, so the order would allow her physician to continue the prescription. But the fact that Bailey could make the move unilaterally felt ominous about her future in Missouri. 

The couple foresees more barriers for Hart-Smith to continue estrogen, so they are selling their home and moving out of state. The decision weighs heavy, as both grew up in rural Missouri and thought they’d always live within sight of the Missouri River.

“I feel like our own state is being held hostage,” Hart-Smith said. “No one wants things like this, not remotely enough for it to be a majority, for this to be the will of Missourians.”

After years of efforts to limit access to certain medical procedures for transgender youth, the Missouri Attorney General’s emergency rule is the state’s first action affecting transgender adults — a step many feared was on the horizon.

The emergency rule’s announcement has been the final push for some Missourians to leave their homes to safeguard their, or their loved one’s, access to medicine.

A trend

Erin Reed, a researcher and advocate for transgender people, created a map of gender-affirming care providers four years ago and began hearing about legislation and reporting on standout bills. Now, she spends 19 hours a day watching committee hearings, reporting on legislation and tweeting live updates on bills around the country.

Reed places states on tiers according to a risk assessment of the bills being proposed and passed. Missouri is in the highest-risk tier by her assessment, she said.

“The reason I have Missouri ranked so highly is because of the ways in which the laws target the community there,” she said. “Missouri is the only state right now with an active or almost active proposal that will target health care of transgender adults and pull them off their medication, as well as transgender youth.”

The attorney general’s order is beyond what some of his fellow Republicans think is necessary.

State Sen. Rick Brattin, R-Harrisonville, said during a discussion last month of a ban on minors receiving gender-affirming care that he draws a line at children.

“If you’re an adult, and you want to go and use (gender-affirming care) and whatever you want to do, that’s at your own accord,” he said in late March.

Secretary of State Jay Ashcroft told the St. Louis Post-Dispatch he thinks adults should be able to make their decisions. He doesn’t think Bailey’s rule will survive a legal challenge. 

Reed says Bailey’s willingness to target adults makes Missouri unique. 

She understands why people are leaving. 

“We’ve moved from sports to targeting trans people in our everyday lives and removing all of our legal protections brick by brick,” Reed said. “Removing our art forms, removing our healthcare access, removing our ability to access gender documents that match our gender, presentation and identity — all of these cumulatively are part of a growing trend.”

There are over 30 anti-LGBTQ+ bills proposed this legislative session in Missouri, including restrictions on drag performances.

Missouri’s proposed ban on gender-affirming care for youth that passed out of the state Senate is like a “carbon copy” of 13 other states’ legislation, Reed said. She believes many of these bills will be reversed in court, but LGBTQ+ Missourians will languish in the meantime.

“They have flooded the zone with these laws,” Reed said. “There are 472 that I’m reporting on all over the United States right now, and it’s going to take years to overturn them in the courts. We will be getting out of this for years.”

Action

Lambda Law and the American Civil Liberties Union have promised to take “any necessary legal action” against the emergency rule.

“This rule is a shocking attempt to exploit Missouri’s consumer protection laws in order to play politics with life-saving medical care,” the organizations said in a joint statement.

Bailey’s order relies on the Missouri Merchandising Practices Act, a law intended to penalize fraudulent businesses like telephone scams. The rule is set to take effect April 27 and expire Feb. 6, 2024.

“The thing that stands out the most is that (the rule) actually is contrary to evidence-based medicine and recommendations from multiple medical organizations,” said Jerrica Kirkley, chief medical officer and co-founder of online gender-affirming care provider Plume.

The World Professional Association for Transgender Health (WPATH), which Bailey cites in part in his order, tells gender-affirming care providers not to require a psychiatrist for every patient.

“Psychiatrists obviously are hard to get into,” Kirkley said. “They can be quite expensive and oftentimes don’t have the full understanding of the lived experience of the patient.”

The emergency rule also prescribes a mental health screening and an assessment for autism. It requires mental illness to be “treated and resolved” prior to receiving gender-affirming care.

This language is reminiscent of an affidavit given to the attorney general by Jamie Reed, a former case worker at the state’s largest youth transgender center.

Reed alleged many patients had mental health comorbidities or autism, and she felt the center didn’t properly address these co-existing conditions. Washington University recently publicized the results of its internal probe of Reed’s allegations, calling them “unsubstantiated.”

Kirkley said people with mental health or autism diagnoses still have autonomy.

“We don’t question somebody’s ability to consent based on co-occurring conditions (in a primary care setting). And so with that same lens, we should not do it in this context either,” she said.

“If this goes into effect, many people’s care will be interrupted,” Kirkley said. “Many people will not be able to engage in care in the state of Missouri, and that has real life-threatening consequences to kids and adults.”

Providers can continue issuing prescriptions and interventions “that have already begun,” according to the rule.

Planned Parenthood of the St. Louis Region and Southwest Missouri opened pop-up clinics beginning last Monday to schedule more patients ahead of the emergency rule.

“Yet again, Missouri Attorney General Andrew Bailey is putting his transphobic, extreme ideology before evidence-based medicine and care,” said Colleen McNicholas, chief medical officer of Planned Parenthood of the St. Louis Region and Southwest Missouri.

Plume, which serves patients 18 and over, is mobilizing Missouri providers to offer access to hormone therapy and support groups for free beginning Monday to Missouri residents.

“When the Missouri Attorney General announced an emergency rule that will severely limit access to gender-affirming medical care and threaten the lives of thousands of trans and nonbinary people, we needed to respond accordingly,” Kirkley said. “Plume is committed to standing with the trans community and will continue to do so in pursuit of our mission to transform healthcare for every trans life.”

She is hopeful, though, that the legal system will intervene.

Hart and Hart-Smith have decided to move regardless if the emergency rule is blocked.

“The problem,” Hart said, “is we don’t trust that this is going to be the end of it.”