The Missouri Save Adolescents from Experimentation (SAFE) Act has survived a legal challenge brought by transgender activists after a two-week bench trial in state court earlier this fall. Judge Craig Carter upheld the law in a 74-page ruling (Noe v. Parson) on Monday, finding that “the court’s limited role” did not permit it to override the legislated will of the people when there is “an almost total lack of consensus as to the medical ethics of adolescent gender dysphoria treatment.”

Missouri Attorney General Andrew Bailey (R) called the decision “a resounding victory for our children” and noted that Missouri was “the first state in the nation to successfully defend such a law at the trial court level.”

The medical, cultural, and political record against gender transition procedures for minors has filled out considerably since a federal judge ruled against the Arkansas SAFE Act in 2023 (Brandt v. Rutledge). Among the evidence Judge Carter was asked to consider were the Cass report, showing increasing international skepticism over gender transition procedures for minors; the WPATH files, showing that professional recommendations were shaped not by medical but political considerations; and testimony from detransitioners like Chole Cole, showing the devastating personal impact these procedures can have.

Perhaps of greatest significance, the state of Missouri presented evidence in court of the abuses that took place at the pediatric gender center of St. Louis Children’s Hospital, run by Washington University in St. Louis. Attorney General Bailey opened an investigation into the clinic’s practices last year after a whistleblower alleged that the clinic distributed gender transition hormones to minors without individual assessment and bullied unwilling parents into providing their consent. In the course of the investigation, Bailey’s office subpoenaed records from the St. Louis center and two other transgender centers in the state. The St. Louis pediatric gender center has since shut down.

“The evidence from trial showed that the medical ethics of gender dysphoria treatment for children and adolescents are entirely unsettled,” wrote Carter. “Essentially, it seems that all of this untested, non-emergency, possibly unethical, possibly unnecessary care would be performed on children and adolescents when the vast majority of minors would simply outgrow the condition by the time they reach adulthood.”

Carter seemed particularly unpersuaded by the challengers’ contention that medical procedures, including gender transition hormones and surgeries, should be exempt from any state supervision whatsoever. “Any person — including a minor — would be able to obtain anything from meth, to ecstasy to abortion so long as a single medical professional were willing to recommend it,” he wrote.

Regardless, “the United States Supreme Court holds that when legislatures deal with areas ‘fraught with medical and scientific uncertainties, legislative options must be especially broad.’ Gonzales v. Carhart, 550 U.S. 124, 163 (2007),” he added. “This is true even assuming, for the sake of argument, that judges with more direct exposure to the problem might make wiser decisions.”

Carter, who received the Missouri Bar’s Judicial Excellence Award earlier this year, convened a nine-day bench trial that ran from September 23 through October 3. He requested concluding briefs from both parties before issuing his final ruling on November 25.

Carter considered the opinions of all four U.S. circuit courts to rule on the merits of laws protecting minors from gender transition procedures. The U.S. Courts of Appeal for the Sixth, Seventh, and Eleventh Circuits each upheld such laws against constitutional challenge, while the Eighth Circuit struck down Arkansas’s law. However, Carter noted, “as the Eighth Circuit has now agreed to hear Brandt again en banc [the whole court instead of a three-judge panel], it would seem that the original holding in that case is not final.”

Of these four opinions, the recent Seventh Circuit opinion was the one he cited in conclusion. “The federal courts do not mediate medical debates,” wrote the circuit court. “Appellees must take their grievance to the people of Indiana — not the courts.” Carter then added, “This Court finds the 7th Circuit’s words extremely persuasive and is in keeping with the court’s limited role.”

The pro-transgender activists who brought the lawsuit, ACLU and Lambda Legal, have signaled their intention to appeal the case within the Missouri court system. However, their appeal may be soon overtaken by events.

Carter’s ruling may be the last judicial word of commentary on the 26 state laws protecting minors from gender transition procedures before the U.S. Supreme Court itself hears the question. Despite the distinctions between state and federal court systems, the Supreme Court’s ruling in Skrmetti will likely have significant implications for any state-court lawsuits regarding laws protecting minors from gender transition procedures.

The Supreme Court has scheduled oral arguments on U.S. v. Skrmetti (the Biden Department of Justice’s challenge to a similar law in neighboring Tennessee) for December 4.