Caleb Bauer held up the vial of testosterone earlier this week, and he hesitated. He’d been taking the hormone every Tuesday since 2018, and the medicine had given him so much peace. The 22-year-old St. Louis resident had barely spoken in the years before he transitioned. Now he felt confident and courageous, more like himself.

Bauer set the testosterone on his desk. CVS had texted him four days earlier to say he didn’t have any refills left, and he wasn’t sure he’d be able to get another prescription. In two days, on April 27, an emergency order would take effect, potentially prohibiting transgender adults across Missouri from accessing hormones. The regulation was the first of its kind in the United States, and Bauer didn’t know yet how it would affect him.

Caleb Bauer, a 22-year-old from St. Louis, has been on testosterone for nearly five years. He fears a new emergency order around transition-related care may prevent him from accessing future doses of the hormones. Taylour Moenster

Two weeks had passed since state Attorney General Andrew Bailey announced the order, and Bauer had done all he could to understand it. He visited an endocrinologist. He called his friends. No one could say for certain what would happen. Bailey’s order was a dense, 11-page document with a dozen subsections and nearly 40 footnotes. Even lawyers at the advocacy group Lambda Legal said the ruling was so “vague and confusing” that they weren’t sure who’d lose access to their hormones. The nonprofit filed suit Monday on behalf of three patients and a St. Louis clinic. A judge will hear their request Wednesday for a temporary restraining order against the regulation.

Bauer heard other transgender people were making contingency plans. Some decided to go “DIY” and order hormones off the internet or from friends in other states. Others planned to move to Minnesota or Colorado, places with firm protections for trans people.

Bauer knew how he’d feel without testosterone. His parents had made him wait until he turned 18 to take the hormone. When that day came, he felt immense relief. Finally, he thought. He had jumped the only hurdle. No barriers remained.

Now, Bauer wondered whether he should ration his supply. If he took his usual dose, he’d be out of testosterone by June. He could stretch the medicine through August, though, if he took just 25 milligrams, half of what he usually injected each week.


“I don’t want to,” he said. “But I’d rather have a smaller dose for a longer time than have to go off it completely. That’s what I’m worried is going to happen. I’m just not going to be able to get more.”


More than a dozen states have banned minors from gender-affirming care, and at least another five have tried unsuccessfully this year to pass bills to curb adults’ access, too. Missouri lawmakers have yet to pass health-care bans for any age, but their efforts have intensified. Between 2018 and 2019, Missouri policymakers introduced just one piece of anti-trans legislation, a bathroom bill that failed to make it out of committee. This session, they’ve introduced at least 36 – a rash of bills that seek to ban drag shows and prevent transgender kids from playing sports or taking hormones.

None of those bills has become law. Then in February, Jamie Reed, a case manager who’d previously worked at the Washington University Pediatric Transgender Center at St. Louis Children’s Hospital, filed an affidavit, alleging that the center fast-tracked children through gender transitions and ignored other mental health diagnoses.

Nearly two dozen parents whose children were seen at the clinic told the St. Louis Dispatch that their experiences “sharply contradict” the ones Reed described in her affidavit. As a case manager, they said, Reed scheduled appointments. She did not have access to exam rooms or the conversations families had with the medical staff. Washington University officials launched an in-depth assessment of the center’s care, which they released last week. They found that Reed’s allegations were “unsubstantiated.” A mental health assessment was required for all medical treatments, the school found, and fewer than half of the center’s 1,165 patients went on hormones. Providers there also had not referred minors for gender-affirming surgeries since 2018, when the center adopted a policy prohibiting referrals.

Still, Reed’s allegations prompted Bailey, whom the governor appointed as attorney general in January, to launch an investigation. (Bailey has not yet released findings from that probe.) In mid-February, he demanded that hospitals cease offering puberty blockers and hormones to minors. Then on April 13, Bailey issued the order that imposed new restrictions on people of all ages seeking transition-related care.


If a patient wants hormones or other transition-related care, the order stipulates, they must have exhibited a “persistent and intense pattern of gender dysphoria” for at least three years, and that dysphoria must be medically documented. Patients have to go through 18 months of therapy with at least 15 sessions, and they have to have “resolved” all other mental health comorbidities. They also have to undergo a screening for autism.

Providers have to assess transgender patients every year to determine whether they still have gender dysphoria, Bailey’s order said. Doctors also have to screen patients to ensure they are not “experiencing social contagion.”

Bailey’s office did not return requests for comment, but he told a conservative podcaster on the Christian network American Family Radio that the order will protect patients.

“The left wants to paint it as some kind of hateful act, hateful behavior, hateful restriction,” he told Jenna Ellis, a podcast host and a former lawyer for Donald Trump. “Really what we’re saying is there’s dignity in human life that should be respected and protected.”


For many transgender Missourians, the week after Bailey announced the order felt chaotic and terrifying. At least one provider told patients that the new regulations were so onerous, they would stop writing gender-affirming hormone prescriptions altogether. Doctors at Southampton Community Healthcare, a nonprofit in St. Louis, testified in legal documents that many transgender adults said the prospect of losing their hormones had caused them to have suicidal ideations.


And in Planned Parenthood clinics across the state, more than 250 people signed up for last-minute appointments. The organization’s staff worked overtime, and they hosted three pop-up clinics the Monday after Bailey’s announcement. Every appointment was claimed by 10 a.m.

Colleen McNicholas, chief medical officer for Planned Parenthood’s St. Louis region, treated many of those patients, and said most appeared “super anxious” about their long-term health.

“Overwhelmingly patient after patient was just terrified and angry,” McNicholas said. “So many of them feel like they finally have found the thing that helps them feel whole and helps them be seen and helps them live healthy lives. Then they wake up in the morning and the attorney general has decided that their life is not worth valuing and that he’s going to take that care away from them.”

Marion Johnson, a 22-year-old nonbinary person in Columbia, had already missed three testosterone shots this spring because of an insurance mix-up. They finally got a refill the day the order came down, but worried they’d do more harm to their system if they started the hormone again, only to have to go off it when Bailey’s order took effect.

Johnson waited to talk to their doctor in Kansas City, but had trouble reaching her. A week after Bailey’s order, Johnson started menstruating, and their dysphoria intensified, so they began taking the hormone again, not knowing if they’ll be able to receive more.



Southampton doctors warned in the Lambda Legal lawsuit filings that some patients may choose to lie about their mental health rather than lose their prescriptions. If they do, the providers said, doctors “will miss serious health issues that could increase morbidities and cause negative health outcomes, including suicidality.”

Clark Roman, a 32-year-old transgender man in St. Louis, said he has considered that option. Roman has been on testosterone for four years, but he’s had documented depression since he was a child. A mix of hormones and an antidepressant has made him feel better, he said, but depression, for many people, never fully resolves. Now, he feels he may have to choose between treatments.

“I asked my boyfriend, ‘Do I just lie and say my depression has resolved itself? Do I go off my antidepressant?’ ” Roman said. “Testosterone does as much for my depression as my antidepressant does. It physically makes a change in my body that makes me feel better.”

Other transgender people say they worry Bailey’s order created a Catch-22. Amelia Jones, a 24-year-old pharmacy technician who lives in Independence, noted that “severe distress” is one of the hallmarks of gender dysphoria.

“Let’s say my depression and my anxiety get solved,” Jones said. “Well, they’ll say, ‘Then you don’t have really bad gender dysphoria, so you don’t need the hormones.'”

Rather than stop taking antidepressants, Roman said he and his boyfriend may move to Minnesota. Neither wants to leave St. Louis. They each own their homes, and Roman loves the work he does at a coding nonprofit. Without the order, Roman said, he and his boyfriend would have put off moving in together for a while. Their relationship is still new, but neither can afford to start over somewhere new alone, and so Roman spent his birthday last weekend cleaning out his basement and applying for jobs up north.


Other trans people said they either don’t have the money to move or they can’t imagine abandoning a place that feels like home. Ophelia Lovejoy said her family disowned her after she came out as trans, and the friends she’s made in Columbia are too important to leave behind.

“We have to protect our communities where they are, and that includes the South and red states,” Lovejoy said. “We want to keep this community alive here, where it is. I really do love this city. I can’t leave.”

As the deadline neared, people said they felt forced into other decisions they were unprepared to make.

In St. Louis, Finn, a 33-year-old agender person who has not come out to their family or co-workers yet, said they hadn’t imagined pursuing medical interventions so soon. They just came out to their therapist in March. They cut their hair into the style ’90s heartthrob Rider Strong used to wear, and they bought a binder to compress their chest, and “felt an absence of the pain that I have carried my entire life.”

Finn has three trans friends, and they know transitioning can be a long process. Many people socially transition, meaning they change their clothes and their hair, long before they access hormones or other medical interventions. Finn wanted to take their time, too.

“My window is just shutting completely,” Finn said a few days after Bailey announced the order. “It really started to sink in. If I want top surgery or medically overseen hormones in Missouri, I have two weeks.”


Finn could buy time by moving, but doesn’t want to. They grew up in St. Louis, and though they lived out west for four years after college, they never stopped yearning for home. Besides, they said, other states could follow Bailey’s example.

“I know enough U.S. history to know that when things go bad in Missouri, it’s about to get very bad everywhere,” Finn said.


Just before Bauer took his weekly shot Tuesday afternoon, his phone pinged with an update from CVS. His endocrinologist had called in a refill. If Bauer picked it up before Thursday, he’d have another month’s worth of testosterone.

He eyed the vial. One month wasn’t much of an assurance, but for now, Bauer decided, he would continue taking his full dose. He flipped off the teal cap, then eased in the syringe. He drew out 50 milligrams, and when he injected it, the shot felt like a mild bee sting on his stomach.

Wednesday, he’d pick up his prescription, and he’d check to see if a judge had ruled on Lambda Legal’s lawsuit. For now, he controlled his own life.

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