The Missouri General Assembly enacted two statutes effective August 28, 2023: the SAFE Act, which generally prohibits health care providers from performing gender transition surgeries or prescribing cross-sex hormones and puberty-blocking drugs for minors, and the Medicaid ban, which precludes MO HealthNet payments for such treatments when used for gender transition. The statutes include specific exemptions, such as for treatment of certain medical conditions and for minors already receiving such care prior to enactment. E.N., on behalf of her minor child and joined by medical professionals and organizations, challenged both laws, alleging violations of equal protection, due process, and the gains of industry clause under the Missouri Constitution.

The Circuit Court of Cole County conducted a two-week bench trial and entered judgment in favor of the State, upholding the constitutionality of both statutes. The court found the challengers had raised only facial challenges and determined that neither statute violated the constitutional provisions cited. The challengers appealed, raising multiple points of error regarding the constitutional analysis and factual findings at trial.

The Supreme Court of Missouri reviewed the circuit court’s determination de novo, applying a presumption of constitutionality. Relying on recent decisions from the United States Supreme Court and the United States Court of Appeals for the Eighth Circuit, the court held that both statutes classify based only on age and medical use, not on sex or transgender status. Thus, rational-basis review applied. The court found that the statutes are rationally related to legitimate state interests, such as safeguarding minors and managing public resources, and do not infringe fundamental rights. The court affirmed the circuit court’s judgment, concluding that the challengers failed to demonstrate any constitutional violation.