After three days of contentious debate over scientific papers and expert testimony, the trial over Missouri’s restrictions on gender-affirming treatments turned its focus Thursday to the law’s effect on transgender patients and their healthcare providers. Nicole Carr, a nurse practitioner at Southampton Community Healthcare in St. Louis, shared emotional testimony about the toll these restrictions have taken, particularly since Attorney General Andrew Bailey introduced an emergency rule in April 2023 that established new barriers to gender-affirming care.
Carr said transgender patients began experiencing heightened anxiety, fear, and depression immediately after Bailey’s rule was published. The situation worsened when Missouri passed a law in 2023 banning gender-affirming medical treatments for minors. This law, which went into effect on August 28, has led to a chilling effect on providers of gender-affirming care, even as it permits the continuation of treatments that began before its enactment.
“Patients were crying in the clinic in fear,” Carr 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. It’s sad because I’m referring a lot of people to therapy that, before these rules, were fine,” she added.
Carr, Southampton Healthcare, and 10 additional plaintiffs—including parents of transgender children, transgender adolescents, healthcare professionals, and organizations supporting gender-affirming care—have filed a lawsuit against the 2023 law. Their attorneys are asking Judge Craig Carter, presiding over the case in Cole County Circuit Court, to declare the law unconstitutional, alleging violations of equal protection and due process under the Missouri Constitution.
Though the law does not explicitly ban counseling or the continuation of treatments that began before its implementation, its vagueness and potential for litigation have led many healthcare providers to cease all gender-affirming treatments for minors. Both the University of Missouri Health and Washington University in St. Louis terminated their gender-affirming care programs for minors, citing legal uncertainties.
Emotional Impact on Patients and Providers
During her testimony, Carr spoke about the emotional strain she faces in trying to reassure patients. She noted the particular vulnerability of transgender youth in Missouri’s foster care system. Many of these minors are unable to pursue gender-affirming treatments until they turn 18 and can visit a doctor independently. Even so, she continued, a large number of these children are eligible for Medicaid, which by Missouri law does not cover gender-affirming therapies.
“(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,” Carr said.
The trial has drawn significant attention, not only because of its implications for transgender healthcare in Missouri but also for the broader national debate over gender-affirming care. Missouri is one of several states that have recently enacted or attempted to pass laws restricting access to gender-affirming treatments for minors, including puberty blockers, hormone replacement therapy (HRT), and gender-affirming surgeries.
Attorneys representing the plaintiffs began calling witnesses Monday. The trial, which is expected to last until early October, has thus far featured expert testimony from medical professionals in fields like pediatrics, bioethics, and adolescent medicine. These experts have spoken in favor of gender-affirming care as being essential, safe, and effective for treating gender dysphoria, a condition recognized by major medical organizations like the American Medical Association and the American Academy of Pediatrics.
Slow Trial Process and Heated Cross-Examinations
The trial’s progress has been notably slow, with assistant attorneys general defending the law taking a methodical approach to cross-examination. Defense attorneys have challenged the credibility of the plaintiffs’ experts, often scrutinizing their research and clinical experience. This has led to frequent objections from the plaintiffs’ attorneys, who argue that the cross-examinations have turned into personal attacks and deliberate attempts to stretch the trial beyond its scheduled end date of October 4.
“They seem to be reading a lot of newspaper articles and a lot of opinion pieces,” said Omar Gonzalez-Pagan, an attorney for the plaintiffs. “If they wanted to introduce the opinion of some random person in the United Kingdom, they could have called them.”
Judge Carter has allowed the defense to continue these lines of questioning, despite protests from the plaintiffs’ legal team. The judge has emphasized that the defense is entitled to challenge the credibility of witnesses, particularly when questioning the methodologies and conclusions drawn by the plaintiffs’ experts.
One such expert, Dr. Armand Matheny Antommaria, a pediatric hospitalist and bioethicist at Cincinnati Children’s Hospital, was cross-examined about his religious beliefs and how they might influence his testimony. Solicitor General Joshua Divine, defending the law, asked whether Antommaria’s divinity degree should disqualify him from testifying as an expert.
“Given the nature of that particular degree, that does not disqualify myself,” Antommaria replied.
Another key witness for the plaintiffs, Dr. Johanna Olson-Kennedy, a prominent adolescent medicine physician at Children’s Hospital Los Angeles, defended her clinical research on the benefits of gender-affirming care. She has extensive experience working with transgender youth and discussed the mental health improvements seen in patients who receive gender-affirming care, including reductions in depression and anxiety.
Hal Frampton from the Alliance Defending Freedom represented the defense, who spent hours presenting articles and academic papers meant to discredit Olson-Kennedy’s work.*/ Frampton highlighted videos of Olson-Kennedy’s past talks, during which she discussed the seriousness of certain gender-affirming surgeries.
Olson-Kennedy clarified that while some surgeries, such as sterilizing procedures, are more serious, other procedures, like chest surgeries, should not be conflated. “The seriousness of getting a sterilizing surgery is more severe than someone who needs a chest surgery,” she said.
Missouri’s Defense: “Experimental” and Harmful Care
In defending the law, Missouri Solicitor General Joshua Divine has argued that gender-affirming medical treatments for minors are “at best experimental and at worst deeply harmful.” The defense maintains that gender dysphoria is a psychiatric condition and that treatments like puberty blockers and cross-sex hormones are inappropriate and risky for minors.
Instead, the state advocates for therapy as the proper treatment for minors diagnosed with gender dysphoria. “The worst thing that could befall plaintiffs from not receiving an injunction is that individuals seeking treatment for gender dysphoria will receive counseling instead of chemical and surgical interventions. That is no harm at all,” Divine argued in pretrial filings.
However, plaintiffs’ attorneys, including Gillian Wilcox of the ACLU of Missouri, argue that therapy alone is inadequate for treating gender dysphoria and that denying access to gender-affirming care is harmful. “Gender-affirming medical care does not harm transgender youth,” Wilcox said in court. “To the contrary, it allows them to thrive.”
Wilcox noted that the World Health Organization had previously classified gender dysphoria as a mental health condition, but in 2013, it moved the condition to the category of sexual health, reflecting a broader understanding that gender dysphoria is not simply a psychiatric disorder.
The Bottom Line
The outcome of the trial could have far-reaching implications, not just for transgender youth in Missouri but for the broader national conversation about transgender rights and healthcare access. Plaintiffs are seeking to overturn the law on constitutional grounds, arguing that it discriminates based on sex and transgender status, thus violating equal protection rights.
The defense, however, maintains that the state has a compelling interest in protecting children from what they argue are harmful and experimental medical treatments.
The trial is set to continue next week, with both sides expected to call additional expert witnesses. A ruling could come as early as October 2023, though appeals are likely no matter the outcome. For now, Missouri’s transgender minors and their families wait anxiously, hoping for a decision that will allow them to access the care they say is vital to their well-being.
