Doctors question aspects of Missouri transgender care limits

Glenda Starke wears a transgender flag as a counterprotest during a rally in favor of a ban on gender-affirming health care legislation, Monday, March 20, 2023, at the Missouri Statehouse in Jefferson City, Mo. (AP Photo/Charlie Riedel) (Charlie Riedel, Copyright 2023 The Associated Press. All rights reserved.)

Missouri’s attorney general has said he will issue an emergency regulation that at least temporarily puts strict limits on transgender medical treatment for youth. The planned rule comes as legislators in that state and many others seek bans or other restrictions on the treatment.

Doctors and advocates for the transgender community contend the planned rule contains misleading or incorrect information straight from the playbook of anti-trans activists. Here’s a look at what the rule does and what's behind some of its assertions.

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Republican Attorney General Andrew Bailey’s rule will target treatment for gender-questioning children, which typically begins with puberty-blocking drugs to temporarily pause sexual development. They are offered early in puberty, sometimes before the age of 10. Sex hormones — estrogen or testosterone — are offered next, generally in the teen years, allowing transgender boys and girls to physically transition. Some older teens choose to have transgender surgeries.

Bailey’s rule had not been formally filed as of Tuesday, but his office issued a press release outlining what he called “guardrails” for the treatments. The rule will require an 18-month waiting period, 15 one-hour therapy sessions and treatment of any mental illnesses before Missouri doctors can provide that kind of care to transgender children, according to the release. It also requires disclosure of information about puberty blocker drugs.


In the press release about the new rule, the attorney general's office says patients must be told that using puberty blocker drugs or hormones to treat gender identity disorder is “experimental” and not approved by the U.S. Food and Drug Administration.

The FDA approved puberty blockers 30 years ago to treat children with precocious puberty — a condition that causes sexual development to begin much earlier than usual. Sex hormones — synthetic forms of estrogen and testosterone — were approved decades ago to treat hormone disorders or as birth control pills.

The FDA has not approved the medications specifically to treat gender-questioning youth, but they have been used for many years for that purpose “off label," a common and accepted practice for many medical conditions. Doctors who treat trans patients say those decades of use are proof the treatments are not experimental.


The press release says patients must also be told the FDA issued a warning that puberty blockers can lead to blindness and brain swelling.

In April 2022, the FDA added a warning to labeling for puberty blockers based on several reports of a condition called pseudotumor cerebri, which can cause pressure and swelling inside the skull.

The FDA said the condition was found in six patients aged 5 to 12 years. Five of the girls were using the drugs for early-onset puberty. The sixth was using the drugs for transgender care. Their symptoms — including headaches, optic nerve swelling, blurred vision or vision loss — resolved or were resolving in at least four of the patients, the warning announcement said.

The FDA said there were too few cases to estimate how common the condition was in youth using puberty blockers and it did not move to limit their use.

Patients also must be told that Sweden’s National Board of Health and Welfare has declared that the risks of puberty blockers and sex hormones for gender-questioning youth “outweigh the possible benefits,” according to Bailey's press release. The Swedish agency did make that declaration last year, saying that the treatment in youth should be reserved for “exceptional cases,” citing what it said was a lack of strong evidence on effectiveness and safety, and concerns about young patients changing their minds about transitioning.


Evidence suggests detransitioning is not as common as opponents of transgender medical treatment for youth contend, though the few studies that exist have weaknesses.

The release says that the Endocrine Society, which represents specialists who treat hormone conditions, found that about 85% of young children diagnosed with gender dysphoria grow out of it by their teens. The society does make that statement in its guidelines for transgender treatment and recommends against starting puberty blockers before puberty. But a spokesperson said the society opposes using the guidelines to discourage care.

And experts say evidence shows that detransitioning is uncommon in older children who begin treatment after puberty has begun, following recommendations from the society and other medical groups.

Bailey's release says treatment should be denied unless doctors ensure at least annually that “social contagion” has not influenced a patient’s gender identity. It says one study “notes that an individual whose friend identifies as transgender is “more than 70 times” as likely to similarly identify as transgender."

That appears to be a reference to a widely criticized 2018 study that suggested transgender identities among teens could be contagious. The study was based on surveys of a selective group of parents who opposed their children’s gender identities, skewing the results.


Medical associations recommend psychological counseling for gender-questioning youth before starting any treatment. The Missouri regulation says that should consist of at least 15 hours over at least 18 months, the release says.

Critics say that recommendation is prescriptive and arbitrary.

“There is no good scientific evidence to determine how long such an evaluation should last," said Dr. Jack Drescher, editor of the gender dysphoria chapter in the latest edition of the American Psychiatric Association’s diagnostic manual.


Follow AP Medical Writer Lindsey Tanner at @LindseyTanner. ___

The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Science and Educational Media Group. The AP is solely responsible for all content.

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