On Thursday 13 April, Missouri’s attorney general issued an emergency ruling that restricts access to gender-affirming care for both minors and adults, under the guise that hormone therapy is an “experimental use” rather than an FDA-approved treatment. For the past year, transgender youth have been a football for conservative politicians, with their access to gender-affirming care restricted or outlawed in 14 states. But this move by Missouri’s attorney general is the first attack on gender-affirming care for transgender adults; assuredly, it won’t be the last.
The first time I tried to get access to gender-affirming care was in 2003. I was 24 years old and lived in Rhode Island. I’d been out as transgender for eight years by then, eight years spent looking (on a good day) like a 14-year-old boy, until finally the me I saw in the mirror and the me I saw in my head didn’t match any more. Only testosterone would make me feel like myself.
I told my doctor, who was kind and sympathetic and said she had no idea about the protocols for administration of testosterone to a transgender person. She did find me a list of all the practitioners in Rhode Island who offered such care. There were three names on the list. True, Rhode Island is not a large state, but still: three names. I called them all. Only one would see me, and only after I had gone to therapy and had a psychologist certify that I was ready to transition.
That was the standard back then – and that’s what the Missouri attorney general wants to require of adult transgender individuals now, only more extensive. In 2003 in Rhode Island, I needed to see a therapist for at least three visits. The Missouri AG wants documentation of least three years of “medically documented, long-lasting, persistent and intense pattern of gender dysphoria” before an adult can be approved to get hormones. Three years of therapy is lengthy, time-consuming and expensive; three years is a very long time to suffer before being allowed to get medical attention.
Moreover, back in 2003, “gender identity disorder” was in the Diagnostics and Statistics Manual (DSM) as a mental disorder. Doctors required transgender individuals to visit a psychologist so that there was a “legitimate” diagnosis to accompany the prescription of hormones – even though, back then and still today, the use of hormones for gender reassignment is an “off-label” use. But that diagnosis was removed from the DSM in 2013, replaced with “gender dysphoria”.
That’s the term Missouri’s AG uses in his emergency ruling and, in doing so, trying to return to the idea that being transgender is synonymous with being mentally ill, a narrative that the right has used at several historical moments to marginalize LGBTQ+ individuals. The narrative here isn’t really about a diagnosis or medical legitimacy – it certainly isn’t about the health of the transgender person. The subtext clearly is that transgender people are mentally ill and delusional, and they need a medical authority to help them figure out who they are.
The therapist that I saw in 2003 was a gay man who had a lot of compassion for the situation I was in. He knew it was a hoop I had to jump through, and he also knew he had to do his job. He asked me questions, took notes, and eventually wrote a letter certifying that I fit the diagnosis of “gender identity disorder” and that hormone therapy would help treat this disorder.
I felt uncomfortable with the process; it seemed to me then and it seems to me now that there isn’t anything wrong with my gender identity. I know very well who I am; it’s how I feel about my body that needed to be addressed in a medical way. That’s the shift that was made in the DSM – away from “gender identity” and towards “dysphoria”. That’s the shift that the Missouri AG is trying to undo and rewrite.
But that diagnosis and that therapist’s letter got me a prescription for testosterone in Rhode Island, a medical intervention that was absolutely transformative and life-saving for me.
And then I moved to south-west Florida. I called endocrinologist after endocrinologist, asking if they would see me, look at the paperwork from my Rhode Island doctor, look at the letter from the therapist. A dozen said no – one receptionist told me curtly that the doctor didn’t see “transgendereds”. Another hung up on me. A third said, “Are you kidding me?” Eventually, I found a doctor in the Miami area, a three-hour drive away, who agreed to see me.
This was typical for transgender care back then and, sadly, now. Unless you live in or near a major metropolitan area, getting a doctor who is trained, comfortable and willing to provide gender-affirming care is not easy. I was a person with a lot of privilege: health insurance from my employer, a good income, the language and education and time to persist in finding a therapist and a doctor who would treat me. For many transgender individuals, this would be too much, especially to maintain for three years. Missouri is trying to pile more work on to an already significant burden.
But more than the details of this particular attack, I hope people will see the mounting pattern here. The first wave of legislation came for transgender youth. This next wave is coming for transgender adults. Put these restrictions next to the rulings against abortion and you can see a larger picture of bodily control. Who gets to make medical decisions about their bodies? Not pregnant women. Not transgender people.
Back in 2003, I was so frustrated by my own experience that I vowed to work for improvements. I’ve fought for transgender civil rights and worked in particular for transgender students. There were years when we were making headway, when a conversation between a transgender individual and their doctor was sufficient basis to prescribe hormones. Now, it seems like we are at an inflection point. It’s time to strip away the rhetoric and recognize what’s at stake: our rights to control our bodies, our rights to control our identities. And I’m not just talking about transgender people.
Alex Myers is a novelist and teacher who lives in Vermont
