CREVE COEUR, Mo. — Reneé Luckfield tries not to knock like a cop.

In fact, the 29-year-old spends a lot of time thinking about how to make strangers comfortable when she shows up at their door to talk about transgender healthcare. A syncopated "tap — tap-tap-tap" sounds friendly even when she knocks loudly. In each encounter, she masks her own unease.

"Honestly, it's not something that I'm entirely comfortable with," Luckfield, a transgender woman, said while walking door to door in this affluent St. Louis suburb. "And it's not fair that we have to do this work." Transgender issues have become a major theme in this year's midterm elections, especially in Missouri, where voters are weighing a proposed constitutional amendment to bar minors from gender-transition surgery, cross-sex hormone therapy and puberty blockers. The potential ban is part of a proposed amendment to reinstate a near-total ban on abortion in the state.

Voters in four other states will also decide on transgender issues this year: a proposed ban on transgender health care for minors in Colorado, and proposed restrictions on transgender athletes in youth sports in Arizona, Colorado, Nebraska and Washington.

Luckfield is part of an effort by the LGBTQ+ advocacy organization PROMO Missouri to defeat the Missouri measure by knocking on 100,000 doors across five of the state's largest metro areas before the election — an ambitious target the group is trying to reach with a mixture of full-time canvassers like Luckfield, the St. Louis lead, and volunteers who show up on weekends. About one out of every 10 knocks turns into a conversation, and they're aiming to have 10,000 conversations before Election Day.

The group celebrated reaching 6,000 in early October, but the process is slow going, intentionally, as canvassers aim for open-ended, "transformative" conversations with potential voters.

The technique, "deep canvassing," has a history of changing people's perspectives on difficult political topics, including a 2012 campaign that overturned a gay marriage ban in Maine and a 2021 campaign for police reform in Minnesota that, while defeated, triggered new debate. Now, organizers in Missouri hope it can help stave off the latest effort in the state to permanently ban gender-affirming care for minors.

In 2023, Missouri's Republican-dominated legislature permanently blocked minors' access to gender-affirming surgeries and temporarily blocked their access to new prescriptions for puberty blockers and cross-sex hormones for four years. The state is one of 27 that enacted restrictions on gender-affirming care for minors in the past five years.

The deep canvass in Missouri began in 2024, as transgender healthcare was becoming a focal point of state and national elections. President Donald Trump's campaign, and pro-Trump groups, spent millions of dollars that year attacking Democratic presidential nominee Kamala Harris over transgender issues, such as one declaring, "Kamala is for they/them. President Trump is for you." And in Missouri that year, an amendment to add abortion protections to the state's constitution passed by fewer than 100,000 votes.

Opponents argued the measure would also enable the state's ban on gender-affirming care for minors to be overturned. "NO TAX PAID CHILD SEX CHANGE SURGERY" read a sign opposing the amendment.

This year's amendment to reinstate the state's abortion ban and codify the ban on trans healthcare for minors is polling neck and neck, with 43% supportive of the bans, 44% opposed, and 13% undecided, against a margin of error of 4.09%. This most recent poll doesn't ask separately about abortion and gender-affirming care, but polling from February showed stronger support for abortion access. The deep canvassers are trying to reach voters who are against banning abortion but are more ambivalent on trans issues. That means not spending too much time talking to people who are already very opposed or very supportive of the proposed bans.

To discern people's views, canvassers are trained to ask the person they're speaking with to place themselves on a scale from 0 to 10, with 0 being totally opposed to banning abortion and 10 being totally in favor of it. Then they ask the person to use the same scale to rate their feeling toward banning "gender-transition procedures for trans minors" — language similar to what voters will see on the ballot. After each of those questions, canvassers ask why the number the person chose is right for them.

On an overcast Saturday morning in late September, with Missouri's summer heat seemingly broken at last, the sounds of lawnmowers and leaf blowers filled the air as Luckfield began knocking doors in a neighborhood 20 miles west of the Gateway Arch.

The first person who opened their door was a 10/10 in canvasser shorthand — in favor of banning abortion because of her Christian faith and in favor of banning gender-transition procedures for minors because she doesn't think children are equipped to make those decisions and doesn't think parents should either.

"I hear you," Luckfield replied. "That's everything I need from you today. Thank you very much for your time." The exchange wasn't unusual, Luckfield said. Neither was a conversation she had later that morning with Carol Parsons, who said she was opposed to banning both abortion and gender-transition procedures for minors — a 0/0. Luckfield acknowledged Parsons' support and asked if she had any questions about the process kids go through to get care.

"I do feel that they need to be old enough to realize that that is life-changing," Parsons said. Surgery is the thing she's not sure about, she said.

"It is tricky, and it is scary to think of that happening for young kids," Luckfield acknowledged. "The phrase 'transgender procedures' — that's, I think, very deliberately chosen language to stoke that fear of surgeries in particular." Gender-affirming surgeries for minors are rare. One study of 2019 insurance claims for nearly 23 million children found surgeries were performed at a rate of 2.1 per 100,000 for those ages 15-17, 0.1 for those 13-14, and none for those 12 and younger. Prescription treatments are also uncommon, given to fewer than 1 in 1,000 adolescents who have commercial insurance, according to another study.

Luckfield explained to Parsons that in addition to banning surgeries and hormone treatments, Missouri's proposed amendment would ban puberty blockers. She said that puberty blockers are reversible and can be prescribed at an appropriate age alongside counseling and social transitioning to give a child time to mature and make an informed decision about further transitions.

"Well, I definitely agree with that," Parsons replied. "I think that would be a good solution." The final door Luckfield knocked on belonged to Louis Meyer, who had previously spoken to a different deep canvasser and expressed some ambivalence about transgender care for minors. This time, he told Luckfield he was fully against both bans — a 0/0. Luckfield asked what had changed his mind.

"The original question was about where my morals sit and what I would do, which is a different statement than what I want the government to dictate," Meyer replied.

Luckfield knocked on 12 doors in an hour and a half and had conversations with five people, four of whom opposed both bans. Those numbers weren't surprising, Luckfield said, in part because St. Louis County tends to be more liberal than Missouri overall. But she thinks it also reflects something larger.

She pointed to research from the Transgender Law Center finding that when people are asked about their opinions on trans issues, they tend to answer favorably, but when they are asked how they think their neighbors feel, their answers are less certain. "People are more accepting than they think the people around them are," Luckfield said.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.