Missouri Code of State Regulations › Title 15 - ELECTED OFFICIALS › Division 60 - Attorney General › Chapter 17 - Gender Transition Interventions › Section 15 CSR 60-17.010 - Experimental Interventions to Treat Gender Dysphoria

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: The attorney general administers and
				  enforces the provisions of the Merchandising Practices Act, Chapter 407, RSMo.
				  The attorney general may make rules necessary to the administration and
				  enforcement of the provisions of Chapter 407, RSMo, and, in order to provide
				  notice to the public, may specify the meaning of terms whether or not used in
				  the Act. This rule specifies the meanings of certain terms used in the
				  enforcement of the Act and provides notice to the public of their application.
				  This rule does not contain an exhaustive list of practices that violate the
				  Act. Instead, this rule identifies certain specific practices that violate
				  section 407.020, RSMo.
EMERGENCY STATEMENT: Individuals of any age
				  experiencing gender dysphoria or related conditions should be able to and are
				  able to obtain care in Missouri. Often this care takes the form of
				  psychotherapy, also known as talk therapy, rather than any chemical or surgical
				  intervention. As the World Professional Association for Transgender Health has
				  previously put it, this therapy often involves exploring the many influences on
				  a person's gender identity, including "peer and other social relationships,"
				  and ensuring that "gender dysphoria is not secondary to, or better accounted
				  for, by other diagnoses." WPATH, which describes itself as an organization
				  "committed to advocacy" for certain "changes in public policies," has been
				  criticized as an organization far too quick to recommend chemical or surgical
				  intervention. Even still, the organization has "highly recommended"
				  psychotherapy because psychotherapy can "greatly facilitate the resolution of
				  gender dysphoria" and because, through this therapy, many "individuals
				  integrate their trans- or cross-gender feelings into the gender role they were
				  assigned at birth and do not feel the need to feminize or masculinize their
				  body."
But in recent years, the use of other forms of
				  interventions, often without any talk therapy at all, has accelerated
				  exponentially. These include life-altering pubertal suppression, cross-sex
				  hormone therapy, and gender transition surgery-all of which pose very serious
				  side effects.
Many medical organizations have determined that these
				  interventions-as currently practiced-lack solid evidentiary support. For
				  example, Sweden's National Board of Health and Welfare recently declared that
				  there is a "lack of reliable scientific evidence concerning the efficacy and
				  the safety" of pubertal suppression and cross-sex hormone therapy and that "the
				  risks" of these interventions "currently outweigh the possible benefits."
				  Similarly, the U.S. Agency for Healthcare Research and Quality recently
				  determined that "here is a lack of current evidence-based guidance for the care
				  of children and adolescents who identify as transgender, particularly regarding
				  the benefits and harms of pubertal suppression, medical affirmation with
				  hormone therapy, and surgical affirmation." And Finland has openly declared
				  these interventions to be "an experimental practice." Because these gender
				  transition interventions lack a solid evidentiary foundation and pose very
				  serious side effects, they are unlawful under Missouri law absent sufficiently
				  protective guardrails.
Part of the reason for the growing awareness of the
				  lack of solid evidence is that many clinics have adopted practices that deviate
				  substantially from the studies on which they say they rely. For example,
				  although many clinics say that they rely on two Dutch studies to justify their
				  practices, participants in those studies all received psychotherapy, and the
				  studies excluded individuals with mental health comorbidities. Despite these
				  and other limitations of the Dutch studies, some clinics have begun offering
				  interventions to persons who would have been excluded from the Dutch
				  protocol-such as persons experiencing significant mental health
				  comorbidities-all without a comprehensive individualized assessment and often
				  without any therapy at all directed at the patient's comorbidities. Even WPATH
				  acknowledges the problem. Although WPATH is "committed to advocacy" of the
				  "least restrictive" policies and "hope that future research will explore the
				  effectiveness of this model," it admits that "here are no studies of the
				  long-term outcomes of gender-related medical treatments for youth who have not
				  undergone a comprehensive assessment."
This emergency rule is necessary to protect the
				  public health, safety, and welfare, and also to protect a compelling
				  governmental interest as the attorney general is charged with protecting
				  consumers, including minors, from harm and investigating fraud and abuse in the
				  state's health care payment system. Among other reasons, the recent immense
				  increase in the use of these life-altering interventions, which have serious
				  side effects, as well as the recent acknowledgment that these interventions are
				  used in circumstances not supported by solid evidence, makes this issue time
				  sensitive. Further, and independently, a whistle blower has issued a sworn
				  affidavit, alleging that a prominent provider of these interventions in
				  Missouri is systemically failing to comply with the medical standard of care,
				  and an investigation has revealed that some providers in Missouri prescribe
				  gender transition interventions without any individualized assessment, contrary
				  to safeguards established in scientific literature and by medical
				  organizations.
As a result, the attorney general finds that this
				  emergency action is needed because of a compelling governmental interest and a
				  need to protect the public health, safety, and welfare. The scope of this
				  emergency rule is limited to the circumstances creating the emergency and
				  complies with the protections extended in the Missouri and United States
				  Constitutions. The Attorney General believes this emergency rule is fair to all
				  interested persons and parties under the circumstances. This emergency rule was
				  filed April 13, 2023, becomes effective April 27, 2023, and expires February 6,
				  2024.
(1) "Covered Gender
				Transition Intervention" or "Intervention" means the provision or prescription
				of any puberty-blocking drugs, cross-sex hormones, or surgery, for the purpose
				of transitioning gender, decreasing gender incongruence, or treating gender
				dysphoria, and does not include:
(A) Treatment
				for a genetically or biochemically verifiable disorder of sex development such
				as 46, XX DSD; 46, XY DSD; sex chromosome DSDs; XX or XY sex reversal; or
				Ovotesticular disorder;
(B)
				Treatment for precocious puberty; or
(C) For subparagraphs (2)(C)-(K), continuing
				prescription or provision of a specific intervention that has already begun, so
				long as the person or health organization promptly seeks to initiate the
				treatments and assessments called for by these subparagraphs.