Show Me My Rights Guide: Anti-Trans Federal Actions

Gender-affirming medical care” includes puberty blockers, hormone replacement therapy (“HRT”), and gender-affirming surgeries.

“Gender-affirming care” refers to more than just medical care. According to the World Health Organization (WHO), it can include “any single or combination of a number of social, psychological, behavioural or medical (including hormonal treatment or surgery) interventions designed to support and affirm an individual’s gender identity.”

See the AAMC’s website for more information about gender-affirming care.

Yes. Adults (age 18+) who are not incarcerated can still legally access all gender-affirming care in Missouri, including medical care.

However, Missouri law currently bars Missouri’s Medicaid program (known as “MO HealthNet”) from reimbursing the cost of gender-affirming care for trans people of any age. See RSMo. §191.1720 (formerly known as SB 49, the “SAFE Act”). In other words, while a person who has coverage through MO HealthNet can seek gender-affirming medical care, the cost of it will have to come out of pocket and will not be covered.

In August 2023, SB 49 (the “SAFE Act”) banned access to gender-affirming surgery for transgender people incarcerated in Missouri.

On June 30, 2026, Missouri’s Governor signed HB 2009 into law, a new Missouri Department of Corrections (MDOC) appropriations bill that prohibits state funds from covering gender-affirming hormone replacement therapy (“HRT”) for all transgender people incarcerated in state prisons. The one-sentence targeting trans inmates, buried on the final page of the twenty-page budget bill, reads in full: “No funds shall be expended for any cross-sex hormones, or gender transition surgery undertaken for the purpose of any gender transition.” The ban includes no exceptions for inmates diagnosed with gender dysphoria or for those already receiving HRT medication, and it provides no guidance on how to safely taper an inmate off hormones while in state custody. HB 2009 is Missouri’s only anti-trans measure to become law in 2026. It took effect on July 2, 2026. *Note: On August 27, 2026, a lawsuit was filed in state court on behalf of a Missouri taxpayer challenging 18 distinct substantive-policy riders that the 103rd General Assembly embedded within eight of the general appropriation bills (including HB 2009) comprising the State’s fiscal year 2027 operating budget. The lawsuit alleges that the eight appropriations bills violate the single-subject and clear-title requirements under the Missouri Constitution. See Mo. Const. art. III, § 23. This lawsuit is ongoing.

No. Since 2023, Missouri has banned gender-affirming medical care for minors, with very limited exceptions. See RSMo. §191.1720 (formerly known as SB 49, the “SAFE Act”). Under this law, health care providers in Missouri are prohibited from performing gender-affirming surgery and from prescribing or administering hormone therapy and puberty blockers to trans youth who are under age 18.

The law also bars Missouri’s Medicaid program (known as “MO HealthNet”) from reimbursing the cost of gender-affirming care for trans people of any age. Medicaid is a federally funded insurance program designed to improve health care access and outcomes for low-income people. Each state administers its own Medicaid program.

This law also effectively prevents out-of-state doctors from using telehealth to treat minor patients physically located in Missouri. There is no prohibition on a person traveling out of state to obtain medical care.

Yes. Transgender minors can still access mental health care in Missouri. For example, a therapist can use affirming pronouns for a trans child. Current Missouri law does not bar or regulate mental health care for trans youth.

In its original passage of SB 49, the Missouri General Assembly allowed for both an exception for transgender youth currently receiving prescribed puberty blockers and hormone therapy to continue to receive that particular treatment but not transition to a new medical treatment (i.e., the “grandfather clause”) and an expiration date (i.e., the “sunset clause”) for restricting this medical care for minors that would cause the entire law to expire in August 2027. (*Note: the sunset provision applies only to minors’ access to puberty blockers and hormone therapy; the ban on minors receiving gender-affirming surgery in Missouri is permanent.)

During the 2026 Missouri legislative session, a proposed bill (HB 2033) sought to remove these provisions. This bill was defeated. As a result, the law’s provision barring health care providers from prescribing or administering puberty blockers and hormone therapy to trans youth under the age of 18 is still set to expire on August 28, 2027. However, in practice, providers have already ended this care for patients in the state in response to SB 49, and future attacks from the Missouri legislature are expected in 2027.

No. Unfortunately, a local “safe haven ordinance” cannot restore the ability for minors to obtain gender-affirming medical care within Missouri without violating current statewide law. See RSMo. §191.1720.

No. Missouri law does not penalize or criminalize parents or guardians who seek gender-affirming medical care for their minor children, including those parents who travel out of state to seek this necessary medical care.

Instead, SB 49 threatens health care professionals who provide this care in Missouri with the loss of their medical licenses​. See RSMo. §191.1720.

No. Missouri law does not bar health care providers from referring patients to out-of-state providers for the purpose of obtaining gender-affirming medical care where it is still legal to do so.

In June 2025, in United States v. Skrmetti, the U.S. Supreme Court ruled that Tennessee’s law banning gender-affirming medical care for minors does not violate the U.S. Constitution’s Fourteenth Amendment Equal Protection Clause. The Skrmetti decision allows Tennessee’s law, along with laws like Missouri’s ban on gender-affirming medical care for minors, to remain in effect.

Then, in January 2026, in E.N. v. Kehoe (formerly Noe v. Parson), a case that challenged SB 49 in state court under the state constitution and that was already on appeal when Skrmetti was decided, the Missouri Supreme Court cited Skrmetti in unanimously affirming SB 49 and the medical care it banned. The decision in E.N. allows the state to continue denying transgender youth access to medically necessary healthcare in Missouri.

*See our state and federal case updates for more information.

No. Since 2023, Missouri law bars MO Medicaid (also known as “MO HealthNet”) coverage for gender-affirming medical care for trans people of any age. See RSMo. §191.1720 (formerly known as SB 49, the “SAFE Act”).

First, you might be wondering what Medicaid and Medicare are. See below for a quick intro:

What is Medicaid? Medicaid is a federally funded insurance program designed to improve health care access and outcomes for low-income people. Each state administers its own Medicaid program. Missouri’s Medicaid program is known as “MO HealthNet.” *You can learn more about the eligibility requirements for MO HealthNet coverage here.

What is Medicare? Medicare is the federal government’s national health insurance program primarily for people age 65 or older, as well as younger people with specific disabilities or permanent kidney failure.

Now, let’s turn to the rules:

1) Withholding Medicaid Funding Rule

On August 13, 2026, the Centers for Medicare and Medicaid Services (CMS) published a finalized rule that bans federal Medicaid funding for gender-affirming hormone therapy (“HRT”), puberty blockers, and surgeries for transgender minors. Under this rule, starting October 13, 2026, states will no longer be able to access federal Medicaid funding for gender-affirming medical care, which the Trump administration refers to as “sex-rejecting procedures.”

This rule does not cut off federal funding for psychotherapy related to gender dysphoria, and states may still choose to use their own funds to cover gender-affirming medical care for minors in Medicaid or the Children's Health Insurance Program (CHIP).

This finalized rule is not a federal ban on gender-affirming medical care for minors. No such federal ban exists in the U.S. Many states have actually enacted laws protecting this care (see MAP's website).

This finalized rule will disproportionately harm low-income transgender minors and their families, who rely on Medicaid to access this care. It has already faced a legal challenge. On September 2, 2026, a coalition of 21 blue-state attorneys general and the governor of Pennsylvania filed a federal lawsuit in the District of Massachusetts against the Trump administration, alleging that the new rule oversteps the administration’s authority. The lawsuit is ongoing.

*Note: Missouri law already bars Missouri’s Medicaid program (“MO HealthNet”) from reimbursing the cost of gender-affirming medical care for trans people of any age. See RSMo. §191.1720 (formerly known as SB 49, the “SAFE Act”). 

2) Withholding Medicare Funding Rule

The Trump administration has reportedly shelved a separate rule that would withhold Medicare funding from hospitals that provide gender-affirming medical care to transgender minors.

However, the mere existence of this proposed rule (even though it has not been finalized) has unfortunately led numerous hospitals across the country to cease providing gender-affirming medical care to trans minors.

Yes. We’ve highlighted a few here to get you started. (And you can find more under the “Resources” tab below!)

• The Campaign for Southern Equality’s (CSE) Trans Youth Emergency Project (TYEP) accepts applications from parents or legal guardians of a transgender person under the age of 18 whose access to healthcare has been impacted by a restriction on gender-affirming care. Visit their website for more information and to apply for support.

• Point of Pride is a trans-led nonprofit providing financial aid and direct support to trans folks in need of health and wellness care. Visit their website for more information and to apply for support.

• The Black Trans Travel Fund (BTTF) provides Black trans women with financial and material resources towards education, community, safety and removing travel barriers. Visit their website for more information and to apply for support.

• The Queer Trans Project has partnered with Elevated Access to provide free flight assistance for trans and nonbinary people who need to travel for gender-affirming care domestically (only in the United States). Visit their website for more information and to apply for support.

In response to growing attacks on gender-affirming medical care, some states have enacted shield (or “refuge”) laws with the purpose of “shielding” trans minors and health care providers from extradition, civil lawsuits, investigations, and professional discipline for activities related to medical gender-affirming care that are legal in the state where the care is received or provided.

For example, Illinois’ Gender Affirming Healthcare Equity Act bars state agencies from cooperating with out-of-state investigations or arrests related to gender-affirming care because such care is legal in Illinois. See this fact sheet from The Williams Institute at UCLA Law for more information.

You can also visit MAP’s website here for information on which states currently have active “shield” laws in place.

“Conversion therapy” refers to dangerous and discredited therapeutic practices that attempt to change a person’s sexual orientation and/or gender identity through talk therapy. There is no statewide ban on this therapy, but some localities have banned it, and the issue is currently being litigated in Missouri related to a ban in Kansas City and Jackson County. As discussed below, this type of therapy has also been protected by a U.S. Supreme Court Decision.

Kansas City banned conversion therapy for minors in 2019 (see Sec. 50-234 "Conversion therapy of minors prohibited”), and Jackson County enacted its own ban in 2023 (see Ordinance No. 5726, enacting sections 667. and 5575., Jackson County Code, relating to a ban on conversion therapy for minors).

In February 2025, the Alliance Defending Freedom (ADF) filed a federal lawsuit on behalf of Christian licensed counselors in Kansas City challenging the ordinances passed by Kansas City and Jackson County that prohibit conversion therapy for minors. (See Wyatt Bury, LLC v. City of Kansas City.) The Missouri Attorney General intervened in the lawsuit as a co-plaintiff. The counselors brought constitutional claims against the city and county and requested a preliminary injunction (i.e., a temporary court order issued before or during trial to maintain the current situation until the court can make a final decision). In July 2025, the federal district court granted a narrow injunction, blocking Kansas City from compelling counselors to use pronouns inconsistent with their faith under a public accommodations ordinance, but denied the requested injunction and dismissed the counselors’ First Amendment free speech claim against the ordinances. (Read the decision here.) The counselors then appealed the decision to the U.S. Court of Appeals for the 8th Circuit.

While the appeal was pending, the U.S. Supreme Court decided Chiles v. Salazar in March 2026. In Chiles, the nation’s highest court ruled (8-1) that a similar ban in Colorado likely violates the licensed mental health professionals’ free speech rights under the First Amendment and sent the case back to the lower court.

In response, in May 2026, the Kansas City Council voted (7-5) to voluntarily repeal its ordinance banning conversion therapy for minors. The Council majority argued that the repeal was necessary to avoid ongoing and future legal challenges following Chiles. Kansas City leaders are now advancing a revised conversion therapy ban that they state is designed to withstand the Supreme Court’s ruling in Chiles. *For updates, visit the city clerk’s website here.

Meanwhile, in July 2026, the 8th Circuit sent Missouri’s case (Wyatt Bury LLC v. City of Kansas City) back to the U.S. District Court for the Western District of Missouri for further review in light of the Chiles decision. Litigation is ongoing.

*If you are a survivor of conversion therapy, you are not alone. Check out resources like the Conversion Therapy Survivor Network and The Trevor Project for support.

For information on which states currently ban gender-affirming medical care for transgender youth and which remain safe to seek such care, visit the Movement Advancement Project (MAP)’s website here. You can also check out Erin in the Morning for an updated “anti-trans national legal risk assessment map.”

Currently, Illinois is the closest state to any part of Missouri that does not have any current or pending bans on gender-affirming medical care for minors. Other regional “safe” states include Minnesota, Colorado, and New Mexico. (MAP’s website has more information on individual states.)

If your question isn’t addressed above, you may submit it to showmemyrights@aclu-mo.org. Submissions are used to develop general guidance for the public and do not constitute individualized legal advice. This inbox is monitored regularly, but due to volume, we cannot guarantee an individual response to every email received.

This is one section of a multi-part guide. You can find the full guide here:

Trans Justice in MO

Trans joy is a form of resistance. It reminds us that, despite everything, trans people lead full, complex, and beautiful lives.

The ACLU of Missouri's Show-Me Trans, Gender Non-Conforming, & Intersex Missourians Belong Storytelling Project is amplifying stories of joy and allyship from people like you!

TGNCI Missourians (ages 18+): Share your story

Loved ones & allies: Show your support

Everyone deserves access to the care they need to live freely. Here are a few organizations that help TGNCI people access gender-affirming care, including financial assistance, travel support, finding an affirming provider, health insurance navigation, and recovery support:

• Campaign for Southern Equality’s Trans Youth Emergency Project (TYEP)
• Flight Assistance - Queer Trans Project x Elevated Access
• Point of Pride
• T4T Caregiving
• Black Trans Travel Fund (BTTF)
• Dem Bois Inc.
• For The Gworls
• Trans Resistance Network
• Nicolas Gogan Foundation (NGF)
• The National Black Trans Advocacy Coalition (BTAC)
• Advocates for Trans Equality (A4TE)’s Trans Health Project
• Plume Clinic
• FOLX Health
• OutList
• InReach

If you feel you have been the victim of discrimination based on your gender expression or identity, please consider contacting the ACLU of Missouri for help.