After three days of battling over scientific papers and expert testimony, the trial of a lawsuit challenging Missouri’s restrictions on gender-affirming treatments on Thursday turned to the impact the law has on patients and providers.

Nicole Carr, a nurse practitioner at Southampton Community Healthcare in St. Louis, said anxiety, fear and depression first increased in transgender patients when Attorney General Andrew Bailey published an emergency rule that established barriers to care in April 2023.

“No one thinks about how these laws affect the actual people they are supposed to protect and they are supposed to serve,” she said.

Patients were crying in the clinic in fear, she testified.

“I’m trying to give them hope that they don’t have to fear being in Missouri, that they don’t have to fear coming to me as a provider, that they can move past this,” Carr said. “It’s sad because I’m referring a lot of people to therapy that, before these rules, were fine.”

She worries about youth in foster care, which she worked with frequently in a previous position. Transgender teenagers in foster care often must wait until they turn 18 to go to the doctor alone for assessment to obtain hormone-replacement therapy.

But if they are on Medicaid, as most are soon after foster care, Missouri won’t pay for the treatment.

“(The law) has impacted the quality of care I can give my patients when I know the solution to their problem is out there and I can’t do anything about it,” she said.

Carr and Southampton healthcare are among 11 plaintiffs hoping to block enforcement of a 2023 law banning gender-affirming medical treatments for minors. Other plaintiffs include parents of transgender children, transgender adolescents, other medical care providers and organizations supporting gender-affirming care.

Their attorneys began putting witnesses on the stand Monday in the Cole County Circuit Court trial scheduled to continue through next week. The lawsuit asks Judge Craig Carter, assigned to the case from Wright County, to declare the law unconstitutional, alleging violations of equal protection, due process and other rights guaranteed by the Missouri Constitution.

Although the law does not ban counseling or the continuation of treatments begun before it passed, several providers ceased all gender-affirming treatments for minors soon after it took effect on Aug. 28, 2023. First University of Missouri Health, then Washington University  in St. Louis, ended their programs, citing the threat of future litigation allowed in the law.

Neither provider is a party to the lawsuit.

Over the first three days of the trial, assistant attorney generals defending the law have repeatedly sought to discredit plaintiffs’ expert witnesses. The painstaking cross examinations have slowed the pace of the trial to two experts per day and led to a late recess on Wednesday.

Carter, however, has declined to limit the cross-examination, despite arguments from plaintiffs’ attorneys that it means the trial will exceed the time allotted to complete it.

During cross-examination, members of the defense team have read scientific articles, news articles and editorials on gender-affirming care. Almost invariably, that leads to objections that the exhibits are new.

Carter has allowed reading as a way to challenge the credibility of witnesses by  showing deficiencies in their testimony, such as bias or poor memory.

“They seem to be reading a lot of newspaper articles and a lot of opinion pieces,” Omar Gonzalez-Pagan, an attorney for plaintiffs, told reporters. “If they wanted to introduce the opinion of some random person in the United Kingdom, they could have called them.”

During one question to Dr. Armand Matheny Antommaria from Solicitor General Joshua Divine, plaintiffs’ attorney Nora Huppert objected, arguing that it was as if Divine was testifying himself.

It came as Antommaria, a pediatric hospitalist and bioethicist at Cincinnati Children’s Hospital, answered questions slowly, often with a “yes sir” or “no sir,” correcting Divine’s questions.

“If you go to the key findings, the statement you’ve pulled out is not part of the key findings,” he said, after a question in which Divine asked about a singular sentence of a scientific article. The context is important, Antommaria told him, saying the overall report was the opposite of Divine’s characterization.

Divine also asked  if Antommaria’s religious beliefs or divinity degree should disqualify him as an expert.

“Given the nature of that particular degree, that does not disqualify myself,” he said.

Dr. Johanna Olson-Kennedy, an adolescent medicine physician at Children’s Hospital Los Angeles and medical director of the hospital’s center for transgender youth health and development, testified about her research linking distress about breast development to depression and anxiety. She also discussed benefits of gender-affirming care she has seen in her clinical experience.

Hal Frampton, senior counsel with the Alliance Defending Freedom, brought one of the 11 three-ring binders prepared for the Olson-Kennedy testimony to the podium. He flipped through the approximately three-inch binder, presenting studies and articles to question Olson-Kennedy’s research and concluding with videos from talks she gave years ago.

In one talk, she said people “get worked up” about certain surgical procedures that are part of gender affirming care.

Frampton asked if she doesn’t like people that get worked up. Olson-Kennedy said she was emphasizing the difference between gender-affirming surgeries.

“The seriousness of getting a sterilizing surgery is more severe than someone who needs a chest surgery,” she said.

He also asked about an interview she gave in which she spoke about being involved in social justice efforts.

“People being able to get access to medically necessary care is an advocacy issue,” she responded.

The defense is scheduled to begin arguments Monday, with a scheduled final day of Oct. 4.