Missouri Cut Off Two Inmates’ Hormone Therapy and Called the Court Order Illegal
Forced hormone withdrawal is a medical event, not a budget line.
EMPOWERED TRANS WOMAN
Forced hormone withdrawal is a medical event, not a budget line. The science, the 2018 ruling Missouri is defying, and the narrow recourse left to people in custody.
Missouri put a single sentence in its prison budget, and at least two transgender people lost medicine their own doctors had prescribed.
The sentence lives in House Bill 2009, the appropriations bill that funds the Department of Corrections, and it reads: “No funds shall be expended for any cross-sex hormones, or gender transition surgery undertaken for any gender transition” (Missouri House of Representatives, 2026). Governor Mike Kehoe signed it on June 30, and it took effect July 2 (Sprayregen, 2026; Riley, 2026). No tapering plan. No exception for the people already receiving care. A spending prohibition, and then the pharmacy stops.
According to PROMO, the state’s LGBTQ advocacy organization, the corrections director said the quiet part to lawmakers first. In an account reported by PinkNews and not yet independently confirmed, PROMO says Department of Corrections director Trevor Foley told several state senators on April 29 that the binding 2018 federal court order requiring this care would not be followed, since he considered it “unenforceable and illegal.” By July 8, again per PROMO, at least two transgender inmates had been taken off hormone therapy that had been prescribed and judged medically necessary. The Department of Corrections and Governor Kehoe’s office have said nothing on the record about the removals; at signing, Kehoe framed the law only as keeping taxpayer dollars on the state’s central work rather than elective procedures (Foley, 2026).
Set the budget language aside for a moment. The part that decides whether this is cruelty or bookkeeping is a medical question, not a political one.
What stopping the medicine actually does
Hormone therapy isn’t a cosmetic drip you switch off without consequence. Someone established on estrogen and an anti-androgen, or on testosterone, has a body that has reorganized itself around those levels. Take the hormones away, and the body does not settle back to some neutral factory state. It lurches.
Britt Walsh, who directs transgender health care at Whitman-Walker Health, told Metro Weekly that the danger runs sharpest for anyone who has had testicles or ovaries removed, since those patients no longer produce sex hormones at all and are advised to stay on therapy for life. Cut them off, and you invite rapid bone loss, fractures, cardiovascular strain, and cognitive and mood effects, layered on top of the slow return of the exact body the person spent years moving away from.
The clinical guidelines say the same thing in colder language. The Endocrine Society’s practice guideline flags bone-density monitoring only for patients who stop sex hormones after their gonads are removed (Hembree et al., 2017). The World Professional Association for Transgender Health, in the eighth version of its Standards of Care, treats this as medically necessary treatment and states outright that the standards apply to people who are incarcerated (Coleman et al., 2022). A clinical summary of those standards puts the continuity point plainly: stopping these medications inside a detention facility affects mental health and social functioning, which is why continuing them there matters (Klein et al., 2023). Custody does not change the medicine. It changes who controls the supply.
Be precise about what the evidence shows, since the precision is the argument. The clearest danger is documented for people who have had gonads removed: they no longer produce sex hormones at all, and withdrawal drops them into a hypogonadal state that raises the risk of osteoporosis and the cardiovascular and cognitive effects that go with estrogen loss (Hembree et al., 2017). Even a voluntary, monitored three-month pause in that population produced measurable physical symptoms, hot flushes, sleep disruption, and mood swings, in a 2026 clinical trial. However, the same trial found no group-level change in depression or anxiety over the short term (van Heesewijk et al., 2026). What Missouri did is not that. It is not voluntary, not tapered, and not monitored, and the people it happened to did not choose it.
The outcomes are not soft, either. Access to gender-affirming hormones is associated with lower odds of past-year suicidal thoughts and severe psychological distress (Turban et al., 2022). A review across dozens of studies found the therapy consistently lowers depression and psychological distress (Doyle et al., 2023). A randomized trial found that starting testosterone produced a clinically meaningful drop in both depression and suicidality within three months (Nolan et al., 2023). Read that evidence backward, and you have named the risk of taking the care away. PROMO named it to Foley without a hedge, calling the state’s action “a death wish for transgender inmates” (PROMO, via Wetherill, 2026).
The order Missouri says it can ignore
Missouri is not writing on a blank page, and its own officials know it.
In 2016, a transgender woman named Jessica Hicklin, then serving life without parole in a men’s prison, sued the Department of Corrections for denying her hormone therapy under a rule called the “freeze-frame” policy. If you were not already receiving hormones when you walked in, you could not start, no matter what your doctors said. In 2018, a federal court struck that policy down as cruel and unusual punishment, ordered the state to give Hicklin the care her doctors recommended for as long as she stayed in custody, and barred the freeze-frame rule for every transgender person in Missouri custody, not only her (Lambda Legal, 2018). The state never appealed. It has been settled law in Missouri for eight years.
The rule the court applied is old and blunt. Under Estelle v. Gamble, deliberate indifference to a prisoner’s serious medical needs is cruel and unusual punishment, and a state shows that indifference when it interferes with treatment its own doctors have already prescribed (Estelle v. Gamble, 1976). Hold that next to what Missouri did. The state chose to incarcerate these people. In doing so, it made itself their only doctor, their only pharmacy, their only route to a refill. You do not get to take custody of a body and then defund its medicine.
That is the turn worth naming. The framing being sold is fiscal: taxpayers should not pay for prisoners’ transitions (Foley, 2026). Grant the strongest version of it. A legislature does hold the power of the purse, and courts are right to be wary of ordering a state to spend. But that power has a floor the courts have already drawn. A budget shortfall is not a defense to a constitutional violation: the Eleventh Circuit put it flatly that “lack of funds for facilities cannot justify an unconstitutional lack of competent medical care” for inmates (Ancata v. Prison Health Services, 1985), and the Supreme Court, ordering California to fix its prisons over the state’s cost and sovereignty objections, held that budget shortfalls do not excuse ongoing Eighth Amendment violations, since “prisoners retain the essence of human dignity inherent in all persons” (Brown v. Plata, 2011). The power to decline to spend is not the power to spend your way out of a constitutional duty. The Eighth Amendment is not a line item a legislature can zero out. You can no more defund a prisoner’s constitutional right to medical care than you can defund a prisoner’s right to be fed. Calling a court order “unenforceable and illegal,” as PROMO says Foley did, does not make it either. It makes it defied.
What recourse actually looks like
So what can the two people in that prison do? Less than they should, and the road is narrow.
A prisoner’s route runs through the federal civil-rights statute, Section 1983, which lets people sue state officials for constitutional violations. The Prison Litigation Reform Act blocks the courthouse door until every layer of the prison’s own grievance process has been exhausted first (42 U.S.C. § 1997e). The realistic remedy for someone still inside is an injunction ordering the restoration of care, which is exactly how Hicklin won, and courts have proven willing to order sweeping and expensive fixes when a state’s prison medical care crosses the constitutional line (Brown v. Plata, 2011).
The catch is the courtroom that would hear it. This is not 2018. Missouri sits in the Eighth Circuit, and in August 2025, that court, sitting en banc, upheld neighboring Arkansas’s ban on gender-affirming care for minors, relying on the Supreme Court’s decision that year in United States v. Skermetti (ACLU, 2025). Prison care for adults is a different question from care for minors, governed by a different clause. What it signals is a bench far less friendly to this care than the one that ruled for Hicklin. A state that stops the medicine, calls the old order illegal, and waits looks like a state betting the fight will be relitigated now, before judges more willing to let a freeze-frame stand.
The coalition that showed up
On July 16, the people with the most to lose refused to let the decision pass in silence.
PROMO held a press conference with Rep. Wick Thomas, Missouri’s first openly transgender and nonbinary state legislator, alongside members of the LGBTQ+ Faith Alliance of Greater St. Louis, a group of health care professionals, and members of Black & Pink, a national organization for LGBTQ people who are incarcerated. Jessica Hicklin, who won her own care in that 2018 ruling and now watches the state defy it for others, also spoke (Wetherill, 2026).
In a letter to Foley, PROMO wrote that his “actions are both cruel and unusual, and thus unconstitutional,” and implored him to stop using “the health and lives of transgender inmates as pawns in fabricated culture wars” (Wetherill, 2026). State Senator Patty Lewis, in a statement, added that legislating this through the budget is itself unconstitutional, since the Missouri Supreme Court ruled as recently as 2024 that the state constitution forbids using appropriations bills to make substantive law, and that the whole effort “will certainly cost taxpayers through expensive litigation once again” (Wetherill, 2026). As of this writing, no lawsuit has been filed. The letter promises one.
The only difference is the door
I am a transgender woman. I take a small dose on a schedule, the way other people take the thyroid or blood-pressure medication they will be on for the rest of their lives, and I don’t think about it much until someone proposes taking it away.
The two people in Missouri custody carry the same diagnosis I do. Their doctors reached the same conclusion mine did. The standard of care does not change inside a prison, and the science does not stop at the razor wire (Coleman et al., 2022). What changes is that I can walk into a pharmacy tomorrow morning, and they cannot. The state took custody of their bodies, appointed itself their only physician, then wrote one sentence into a budget to stop being that physician. They cannot switch doctors. They cannot drive to the next county. They can file a grievance and wait, inside the exact policy a court already called cruel, under the exact department a court already ordered to stop.
That is the test, and it is being run on the people least able to refuse it. If a state can defund a constitutional obligation by burying it in an appropriations line and daring the courts to notice, the two people in Missouri are not the last it happens to. They are where it starts.
I fill my prescription tomorrow. The only difference between them and me is a door that locks from the outside.
Grace Ann Hansen is an independent researcher and writer, and an MBA & PhD graduate student in health informatics and artificial intelligence. She is also a published author, a professional musician, a gymnastics coach, and a queer transgender woman living in Sioux Falls, South Dakota. All interpretation, argument, and prose are her own. Correspondence concerning this article should be addressed to Grace Ann Hansen at grace@graceannhansen.com.