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ST. LOUIS, Mo. – Chelsea Freels has spent a good bit of time in 2023 trying to convince Missouri lawmakers to not vote for legislation barring what's known as gender-affirming care for transgender youth like her.

Over and over, the 17-year-old from suburban St. Louis has heard GOP lawmakers talking about how they need to pass legislation to protect people like her. And over and over, she says she replies:

"Protect me from what?" Freels says. " 'Oh no! The kid is getting better grades. Oh no! The scary transgender has friends! What are they going to do? Smile?' "

Despite Freels testifying that gender-affirming care has made her feel much happier and has helped her heal from depression and suicidal thoughts, Missouri lawmakers seem poised to approve legislation that bars puberty blockers, hormone therapy and gender transition surgery for minors.

Intervention from Democrats in the state Senate, though, has made the bill — that's most likely to get approved before the end of session — less restrictive than other GOP states. It now includes provisions that exempt those like Freels who are already receiving treatment.

A surprise announcement from the state AG

But then, a bombshell: Missouri Attorney General Andrew Bailey put forward emergency rules placing barriers to gender-affirming care for minors and adults. The rules are set to go into effect later this week, although opponents filed a petition Monday evening seeking an order to temporarily block implementation.

Bailey says the rules are meant to keep both parents of transgender youth and transgender adults more informed before receiving gender-affirming care, describing them as an "innovative approach" for people to "have all the information necessary to make good decisions."

But LGBTQ advocates across Missouri see the rules as a dramatic departure from the rhetoric used to pass a ban for minors — that it's necessary to protect children — and that it's an existential attack on transgender Missourians.

"We are living through an all-out attack on transgender Missourian's lives and the very ability to exist," says Robert Fischer, the communications director for the Missouri-based LGBTQ advocacy group PROMO.

'Unlike anything we've seen before'

Bailey's move is unusual for a number of reasons, aside from the fact that it affects both transgender minors and adults.

For one thing, the guidelines weren't passed by a legislature or signed by a governor, but rather derived from Bailey's powers to enforce laws around consumer protection. (Officials in Texas and Florida have also used rules to try to limit transgender care.) And the rules are not inconsequential: Providers are barred from giving gender-affirming care if, among other things, someone has not received 15 hourly sessions of therapy over at least 18 months, has not been screened for autism and has not had documented gender dysphoria for three years.

"These are intended to protect all patients and make sure that all patients have access to mental health services," Bailey said in an interview with St. Louis Public Radio.

Despite claims by some Republicans, many health care providers and medical groups, including The American Medical Association, say this kind of care is tested. The AMA calls gender-affirming care, "medically-necessary, evidence-based care that improves the physical and mental health of transgender and gender-diverse people."

But the new rules in Missouri also state that a provider must "ensure that any psychiatric symptoms from existing mental health comorbidities of the patient have been treated and resolved." When asked to clarify what that means, Bailey responded: "Treating these other mental health problems before we race down the road of administration of experimental drugs."

But many medical professionals, like Brandon Hill, strongly dispute Bailey's characterization of gender-affirming care as experimental.

Hill is with Vivent Health, a Milwaukee-based agency with facilities in Missouri. Vivent Health primarily provides care to LGBTQ people, including gender-affirming care. Hill says what Bailey is doing is "unlike anything we've seen before, particularly in that it does include adult individuals over 18."

And while there are exemptions for people in the rules who already receive care, Hill says the guidelines are so onerous that they could block access for everyone.

"This could lead to the discontinuation of that care if the health care providers are not able to meet all these new requirements that are both antiquated and not based in science," Hill says.

Missouri as part of a GOP state trend

As at least a dozen other GOP states pass restrictions on transgender rights this year, there's been some conjecture in Missouri on why it's become such a big issue in this state's politics and policy.

Some say Missouri Republicans are energized to curtail gender-affirming care for minors because of right-leaning media outlets and social media platforms amplifying opposition to transgender rights. And lawmakers, like GOP state Sen. Rusty Black, say that's causing their constituents to demand action.

"I've got grandparents getting a hold of me over these issues," he says.

Others, like Democratic state Sen. Greg Razer, say it's a consequence of the party running out of ideas on how to restrict abortion rights or reduce gun restrictions.

"There's nothing else you can pass, so you have to find a new social wedge issue," says Razer, the only openly gay member of the Missouri Senate. "I think they thought it was going to be critical race theory. That dart didn't stick. They're trying to make it stick to trans kids. If that doesn't do it, they'll go after another one."

And there's some evidence that what Bailey is doing may be too far for some Republicans.

Missouri Secretary of State Jay Ashcroft, a leading GOP candidate for governor in 2024, said that he strongly supports banning gender-affirming care for minors but that he doesn't think the state should be creating barriers for adults.

"I don't think people should do it. But there's a difference between what I think and where I think the government should be involved," Ashcroft said in an interview with St. Louis Public Radio. "If you're an adult and you want to spend your own money, I disagree with you, but it's not my place to tell you that you can't."

Ashcroft told the St. Louis Post-Dispatch he doesn't expect the rules to survive a lawsuit. Bailey dismissed Ashcroft's criticisms.

"I am standing up to make sure that patients have the information they need to make informed health care decisions," Bailey said. "I'm not sure that the secretary of state fully understood the rule when he offered that opinion."

James Thurow and Danielle Meert are the former St. Louis chapter leaders of TransParent — a support group for families with transgender children. They've been testifying against gender-affirming care bans for transgender minors, like their son, for years. They say it's critical for the rules to be challenged in court.

Both Thurow and Meert note that gender-affirming care is already expensive, especially if someone doesn't have insurance that can cover some of the cost. Adding requirements for therapy and autism screenings could place the treatments out of reach for low-income families, they say.

Thurow says he's hoping a successful legal outcome could dissuade other states from following Missouri's lead.

"Having litigation is incredibly important," Thurow says. "And the more it can get codified on a federal level, the better. Because it's going to happen in every possible red state where they can jam this through."

"We will fight this," Meert adds. "We will win. We are on the right side of history, and we are following all of the leading authorities of medicine."

Political boon or bust?

There's little doubt that the struggle over transgender rights will loom large over next year's elections in Missouri. Before Bailey's rules were proposed, the issue was prominent in a number of speeches at the Missouri Republican Party Lincoln Days events — including from U.S. Sen. Josh Hawley.

"We ought to send a clear message, which is a message rooted in the truth of the Bible and all of our history," Hawley, who is running for a second term next year, said. "Which is: 'Guess what? God made you as you are, and there's nothing wrong with that.'"

Some opponents of barring gender-affirming care for adults and minors hope that the issue will backfire on Republicans, especially as younger voters who support LGBTQ rights turn 18 and go to the polls.

Shira Berkowitz, senior director for policy and advocacy for the group PROMO, says they see the GOP push against transgender rights as "a real misunderstanding of who is transgender and what makes somebody transgender."

"From the kids that we see that testify constantly at the Missouri legislature, we've heard them say things like, 'I'm supported in my family. I'm supported in my school. My teachers use the right pronouns for me. My classmates see me as who I am. The only people that don't are our elected leaders in our state,' " Berkowtiz says.

Chelsea Freels says her generation can help turn back policy that could affect people like her.

"Make no mistake, we will probably lose this battle, but we will win the war," Freels says. "The problem is how many casualties and how many bodies laid dead before we got there?"

But Freels won't be in Missouri much longer to see if that backlash comes to pass.

"I do not want to be here anymore. I'm going to college soon," she says. "And you can take a look at all the red states. And I've got a red state hole puncher and the map of the U.S. And those are places that are not on my list anymore. And Missouri is unfortunately one of them."