Missouri Supreme Court upholds state’s gender-affirming care restrictions

The Missouri Supreme Court ruled unanimously to uphold a state law barring minors from accessing gender-affirming care for the purpose of gender transition. Pictured, Judges Kelly Broniec, left, and Robin Ransom listen to oral arguments Feb. 1, 2024, in a case over state Senate redistricting (Pool photo by David Lieb/Associated Press)

The Missouri Supreme Court on Tuesday unanimously upheld a law barring minors from receiving cross-sex hormones, puberty blockers and gender transition surgeries and prohibiting Medicaid coverage of gender-affirming care for all ages.

The decision, written by Judge Kelly Broniec, affirms a 2024 Cole County Circuit Court ruling from that sided with the state on all counts. Both courts rejected arguments that the law should be subject to heightened scrutiny, a standard of review reserved for statutes that classify based on sex or are discriminatory in nature.

“There is no fundamental right to seek care the legislature has prohibited,” Broniec wrote.“Because (the law) does not infringe on a fundamental right, rational-basis review is appropriate.”

Under rational-basis review, a statute is presumed sensible unless challengers can show the law is arbitrary and irrational.

In their arguments, challengers represented by the ACLU of Missouri and LGBTQ+ rights law firm Lambda Legal alleged that the law discriminates on the basis of sex and transgender status. The court’s rejection of this argument was key to upholding the ban.

The law “classifies only based on medical use and age,” Broniec wrote, aligning with a U.S. Supreme Court decision that upheld Tennessee’s gender-affirming-care ban in June and a decision from the 8th U.S. Circuit Court of Appeals that upheld Arkansas’ gender-affirming care restrictions in August.

Challengers attempted to differentiate Missouri’s ban from the case precedents, arguing that Missouri’s Constitution offered more protections than the U.S. Constitution. These arguments were “not persuasive,” Broniec wrote in a footnote.

The U.S. Supreme Court precedent allows lawmakers broad discretion in areas “fraught with medical and scientific uncertainty.” The trial in Cole County spanned two weeks, delving into whether medical experts agreed on the treatment of gender dysphoria, a condition marked by distress felt when one’s gender identity differs from sex as assigned at birth.

Challengers insisted that gender-affirming care is “evidence-based” and “medically necessary,” with physicians and patients testifying about their positive experiences and defending a widely adopted standard of care from the World Professional Association for Transgender Health.

But the state criticized this standard of care with witnesses who painted the association as an activist group. Some of the state’s expert witnesses admitted to be outliers, calling themselves victims of “cancel culture.”

The testimony was deceptive, Lambda Legal attorney Nora Huppert said in oral arguments in September, and the trial court’s decision included “legal and factual errors.”

Tuesday’s decision didn’t delve into the alleged errors, saying that argument was “moot.”

“The state has demonstrated the ongoing debate among medical and ethical experts regarding the risks and benefits associated with the treatments at issue,” the decision says.

Claims that the Medicaid ban violated the state’s constitution were also thrown out. Adults can still access gender-affirming care if they pay out-of-pocket, the ruling notes, but the state cannot be obligated to cover the care through its Medicaid program.

“The state has a legitimate interest in ensuring limited public funds are used efficiently,” Broniec wrote.

Attorneys with the ACLU of Missouri and Lambda Legal have not said outright whether they will appeal the decision. Though Huppert said in a statement to press that attorneys “will continue to explore every legal avenue to protect the rights and health of transgender people in Missouri.”

“Today’s decision allows the state to continue to enforce a harmful ban that singles out transgender Missourians and denies them compassion and equal access to medically necessary health care,” said Gillian Wilcox, director of litigation at the ACLU of Missouri. “The decision not only allows the state to target transgender Missourians access to health care but also leaves everyone’s health care options at the whims of politicians, should certain care ever fall into the political arena.”

Missouri Independent is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Missouri Independent maintains editorial independence. Contact Editor Jason Hancock for questions: info@missouriindependent.com.