Missouri voted to codify abortion rights into the state’s constitution in 2024, but anti-abortion advocates are trying a new strategy to undo it: tying another anti-abortion ballot measure to one that also bans gender-affirming care for minors.
The abortion rights amendment passed with 51.6% of the vote in 2024 — a number so close that anti-abortion leaders believe they can change the outcome this time around, particularly with the anti-trans language attached. (Missouri already bans gender-affirming care for trans youth under state law.)
“It’s good politics,” said Missouri Sen. Josh Hawley.
Polling shows that abortion restrictions are far, far less popular than bans on gender-affirming care: In Missouri, only 24% of voters think minors should have access to hormone therapy or puberty blockers.
“That can certainly strengthen the probability of success,” said Frank Pavone, national director of the anti-abortion organization Priests for Life, which campaigned heavily against the 2024 abortion rights referendum.
Pavone said opposition to both abortion and gender-affirming care is “part of the same piece of the same cloth.” He told NOTUS that other states could follow Missouri’s example if it succeeds because “it can help on a PR level, as well as in policy making.”
“Whether a voter sees it as connected or not isn’t going to really be the issue. It’s going to be, how are we going to motivate the base to come out and vote the right way on this? So I think adding the transgender part of it, first of all, it adds real protections for minors, and secondly, it adds more voter motivation,” Pavone said.
The anti-abortion amendment, which is set to appear on the November 2026 ballot as Amendment 3 (the same as the 2024 abortion rights initiative), would make abortion available only in cases of medical emergencies, fetal anomalies, rape or incest and would declare that people younger than 18 cannot get “gender transition surgeries” or “cross-sex hormones or puberty-blocking drugs … for the purpose of gender transition.”
Unlike the 2024 initiative, which was added to the ballot through a signature collection campaign conducted by abortion rights groups, 2026’s Amendment 3 originated in the Missouri Legislature. State Republican lawmakers argued that adding the gender-affirming care ban to the amendment was necessary because the 2024 constitutional amendment could be used to challenge the state’s existing ban on transgender health care for minors. (The 2024 amendment does not explicitly mention gender-affirming care).
Republican state Rep. Ed Lewis, who introduced the amendment in the Missouri House of Representatives, told NOTUS that the amendment passed in 2024 does not use the word “woman” and instead says that the government cannot interfere with “a person’s fundamental right to reproductive freedom.”
“Why would you state it that way if your intention wasn’t to say that gender-transition care is reproductive health care?,” Lewis said. “Then once it’s in the constitution of the state of Missouri, even if we create a law that says … that you can’t do that, that law can be found unconstitutional if a judge decides that that is the interpretation of the language.”
The Missouri Constitution says that a person has the right to make decisions about reproductive health care, “including but not limited to prenatal care, childbirth, postpartum care, birth control, abortion care, miscarriage care, and respectful birthing conditions.”
“The key word in the phrase was ‘but not limited to,’” said Brian Westbrook, executive director of the anti-abortion group Coalition Life, which campaigned last year against the amendment. “The 2024 Amendment 3 did, in fact, speak about sex-change operations without actually naming them out loud.”
But for opponents of Amendment 3, the addition is misleading.
Maggie Olivia, policy and external affairs director of Abortion Action Missouri, which led the campaign in 2024 to get the amendment on the ballot and is now leading the opposition to Amendment 3, told NOTUS that Republicans adding a gender-affirming care ban is “one piece of the package of deceit that this amendment is wrapped in.”
Olivia added that “the number one thing that we’re trying to communicate to folks right now is like, ‘Literally last year, you ended the abortion ban, now these corrupt politicians are going to try to trick you into banning [abortion] again. We know you won’t be fooled, we’re going to stop the ban.’”
The ACLU of Missouri is suing the Missouri secretary of state over the ballot amendment’s language, arguing it is “misleading and inaccurate.” The organization is asking the state court to either prohibit the amendment from being on the ballot or reword it. A hearing for the case is set to take place on Aug. 27.
Under state law, a constitutional amendment is required to only deal with a single subject and must be considered “necessary to effectuate a single legislative change.” The ACLU of Missouri says the anti-abortion measure violates that law by grouping gender-affirming care and abortion together under the definition of “reproductive health care.”
“That logic is simply not founded in fact,” Tori Schafer, the ACLU of Missouri’s director of policy and campaigns, told NOTUS. “We know that the Missouri Legislature has already banned transgender health care for minors through state statute, and this is them trying to embody that in the state constitution. But that has no policy impact, right?”
Schafer called it “a political maneuver to try and get Missourians to overturn their vote because they know that they can’t win on banning abortion alone.”
But Republican state Rep. Brian Seitz, who co-led the amendment with Lewis in the Legislature, said that both issues fit “under the loose definition” of reproductive health care.
“I think any gender surgery altering the gender that the individual actually is, what their DNA declares, deals with reproductive health care. So this amendment, dealing with the abortion issue, dealing with gender surgeries, revolves around reproductive health care,” Seitz told NOTUS.
“I hope it does inspire other states to do something similar,” Seitz said. “Children need to be protected in a civilized society.”
The 2026 amendment is the first time an abortion ban and gender-affirming care ban are tied together into one constitutional amendment, and it’s also the first time that an anti-trans measure could be added to a state’s constitution.
“We’ve been having so much success just passing this stuff through the Legislature that we haven’t had to do ballot issues. But I fully support this, I think it’s super smart,” said Terry Schilling, president of the conservative American Principles Project, who works with Republicans on the state and federal level on this type of legislation.
“I’m actually encouraging people that are in these blue states that if there are ways to get these initiatives on the ballot,” Schilling continued. “They should work to do that.”
Currently 14 states and the District of Columbia have laws in place protecting access to trans health care. Abortion is protected in 21 states and Washington, D.C.