A temporary ban on gender-affirming care for transgender minors could become permanent if Missourians vote to amend the state's constitution in 2026.
The measure is attached to a ballot initiative that would place a ban on most abortions in the Missouri Constitution. Lawmakers this year approved a bill that asks voters to decide in 2026.
Missouri prohibited providing surgeries and cross-sex hormones to transgender minors in 2023. A sunset clause written into the law means it expires in 2027. If voters approve the upcoming ballot initiative, though, the ban would not only become permanent but would be enshrined in the state constitution.
"It's completely devastating, to be honest," said June Choate, executive director of the St. Louis-based Metro Trans Umbrella Group. "You're denying an essential care that these folks really, really desperately need."
The bill signing off on the upcoming ballot initiative attracted national attention as Republican lawmakers seek to overturn Amendment 3, a measure Missouri voters passed in 2024 that gave residents the constitutional right to an abortion.
The amendment, if passed, would state that "no gender transition surgeries shall be knowingly performed on children under 18 years of age, and no cross-sex hormones or puberty-blocking drugs shall be knowingly prescribed or administered for the purpose of gender transition to children under 18 years of age."
The ban would not apply to treating hormone imbalances or other disorders in non-transgender minors.
Under the approved bill, the ballot initiative will ask if voters want to "protect children from gender transition" and "ensure parental consent for minors," among other measures.
Some politicians have called the initiative's language potentially deceptive, saying it doesn't state that most abortions would be prohibited if the measure passes. It's possible opponents could sue to change the wording that voters will see when they cast their vote.
Rep. Brian Seitz, R-Branson, was one of the bill's handlers in the Missouri legislature.
He said the inclusion of health care for transgender minors made sense to include in the bill, since they both concern reproductive health. Seitz added that gender-transition surgeries and other treatments affect patients' fertility.
"This legislation was very clear in that the abortion issue deals with reproductive health care," he said. "We made sure that this was placed on the ballot and that they are together."
Seitz said minors should wait until they're 18 before they begin such procedures.
"If a person wants to have these surgeries and/or begin hormonal treatments and so forth, they need to have the cognitive ability to make that decision," he said.
The bill was approved amid national outcry from Republican politicians about such care for those under 18.
Earlier this year, President Donald Trump issued an executive order that, while not immediately changing policies, directed agencies to limit access to gender-affirming treatments for minors.
"Medical professionals are maiming and sterilizing a growing number of impressionable children under the radical and false claim that adults can change a child's sex through a series of irreversible medical interventions," the order reads. "This dangerous trend will be a stain on our nation's history, and it must end."
Doctors and medical professionals have spoken out against the movement to limit providing hormones, puberty blockers and other treatments to young patients.
Many professional medical organizations, including the American Academy of Pediatrics and the American Medical Association, support age-appropriate and informed gender-affirming care. Providers said the provision correlates with better mental health outcomes.
Doctors have also noted that a very small number of patients under 18 receive gender-affirming surgeries, and that cross-sex hormone therapy is typically not given to patients before they reach their mid-teens.
Gender-affirming care can also include counseling and non-medical procedures such as voice training and wearing different clothes.
'A blunt instrument'
Some called the inclusion of trans health care a ploy to garner votes for the abortion ban. Amendment 3 won by garnering around 52% of the final vote.
Katy Erker-Lynch, executive director of the Missouri LGBTQ rights group PROMO, said that the group is gearing up to campaign against the ballot measure.
"Abortion won the popular vote with Missouri voters, and politicians know that they would not be able to overturn the newly enshrined abortion protections without weaponizing trans lives," they said. "They're saying, 'OK, well, we can't win this way. What could we do? We can use trans kids, trans youth, trans minors, as political pawns to try to overturn the will of the people.'"
The sunset clause was hard-won, Erker-Lynch said.
"We have fought like hell with partners and will continue to fight to keep that sunset in place because it was a bipartisan agreement," they said.
Even with the sunset clause in place, the ban on transgender care for minors has resulted in fear and some families leaving the state, said Choate of MTUG. Many people have lost hope that the state will allow minors to receive such care.
"You know, no one, no one, thinks [it's] temporary," she said. "It always seems as though there's an attack. Just kind of take more and more and more, especially with how the other forms of the federal administration have been acting as of late."
Particularly for a relatively new and evolving field of medicine such as gender-affirming care, imposing limiting laws could have far-reaching consequences, St. Louis University law professor Kelly Gillespie said.
Unlike statutes, which the legislature can change with relative ease, constitutional amendments can only be changed through another statewide election.
"We don't get into practicing medicine by law making, because laws are just frankly too blunt an instrument for all the nuances of clinical care," she said. "That could be in place for a long, long time, even as nationally, the science evolves, and that care becomes even more clearly evidence-based."
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