Supreme Court of Texas 

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No. 23-0697 

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State of Texas; Office of the Attorney General of the 

State of Texas; Texas Medical Board; Texas Health and Human 

Services Commission; and Ken Paxton, in his official capacity as 

Attorney General of the State of Texas, 

Appellants, 

v. 

Lazaro Loe, individually and as next friend of Luna Loe, a minor; 

Mary Moe and Matthew Moe, individually and as next friends of 

Maeve Moe, a minor; Nora Noe, individually and as next friend of 

Nathan Noe, a minor; Sarah Soe and Steven Soe, individually 

and as next friends of Samantha Soe, a minor; Gina Goe, 

individually and as next friend of Grayson Goe, a minor; 

PFLAG, Inc.; Richard Ogden Roberts III, M.D.; David L. Paul, 

M.D.; Patrick W. O’Malley, M.D.; and American Association of 

Physicians for Human Rights, Inc. d/b/a GLMA: Health 

Professionals Advancing LGBTQ Equality, 

Appellees

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On Direct Appeal from the 

201st District Court, Travis County, Texas 

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Argued January 30, 2024 
2 

JUSTICE HUDDLE delivered the opinion of the Court, in which 

Chief Justice Hecht, Justice Boyd, Justice Devine, Justice Blacklock, 

Justice Busby, Justice Bland, and Justice Young joined. 

JUSTICE BLACKLOCK filed a concurring opinion, in which Justice 

Devine joined. 

JUSTICE BUSBY filed a concurring opinion. 

JUSTICE YOUNG filed a concurring opinion. 

JUSTICE LEHRMANN filed a dissenting opinion. 

A new law prohibits certain medical treatments for children if 

administered “[f]or the purpose of transitioning a child’s biological sex” 

or “affirming the child’s perception of the child’s sex if that perception is 

inconsistent with the child’s biological sex.” TEX. HEALTH & SAFETY 

CODE § 161.702. Before it took effect on September 1, 2023, several 

parents of children with gender dysphoria,1 together with physicians 

and groups that would be affected by the law, sued to enjoin its 

enforcement, alleging that it is facially unconstitutional. The trial court 

concluded that the law likely violates the Texas Constitution, and it 

temporarily enjoined the law’s enforcement. 

On direct appeal of the temporary injunction, we do not attempt 

to identify the most appropriate treatment for a child suffering from 

gender dysphoria. That is a complicated question hotly debated by 

medical experts and policy makers throughout this country and the 

1 According to the American Psychiatric Association, gender dysphoria 

is the psychological distress that results from an incongruence of at least six 

months’ duration between one’s sex at birth and one’s gender identity. AM.

PSYCHIATRIC ASS’N, DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL 

DISORDERS, FIFTH EDITION, TEXT REVISION 511–12 (2022). 
3 

world.2 And, to be sure, neither this Court nor any party to this 

proceeding suggests that children suffering from gender dysphoria are 

undeserving of treatment and support. The reverse is obviously true: 

they, like all children, deserve the most appropriate treatment together 

with support, love, and empathy. We emphasize, though, that the only 

2 As of June 2024, at least twenty other states have enacted restrictions 

on both surgical and nonsurgical treatments for minors similar to those in 

Texas. See ALA. CODE § 26-26-4; ARK. CODE § 20-9-1502; FLA. STAT. § 456.52; 

GA. CODE § 31-7-3.5; IDAHO CODE § 18-1506C; IND. CODE § 25-1-22-13; IOWA 

CODE § 147.164; KY. REV. STAT. § 311.372; LA. STAT. § 40:1098.2; MISS. CODE

§ 41-141-5; MO. REV. STAT. § 191.1720; MONT. CODE § 50-4-1004; N.C. GEN.

STAT. § 90-21.151; N.D. CENT. CODE § 12.1-36.1-02; OHIO REV. CODE

§ 3129.02; OKLA. STAT. tit. 63, § 2607.1; S.C. CODE § 44-42-320; S.D. CODIFIED 

LAWS § 34-24-34; TENN. CODE § 68-33-103; WYO. STAT. § 35-4-1001. At least 

four additional states have enacted laws that prohibit surgical procedures but 

not all nonsurgical treatments. See ARIZ. REV. STAT. § 32-3230; NEB. REV.

STAT. § 71-7304; UTAH CODE § 58-68-502(1)(g); W. VA. CODE § 30-3-20. 

Conversely, at least fourteen states, either by statute or executive order, 

provide various protections for those seeking or providing medical treatment 

for gender dysphoria. See CAL. PENAL CODE § 819; COLO. REV. STAT. 

§ 12-30-121(2); CONN. GEN. STAT. §§ 52-571n(b), 54-155b; 735 ILL. COMP. STAT. 

40/28-20; ME. STAT. tit. 22, § 1508; Md. Exec. Order 01.01.2023.08 (2023); 

MASS. GEN. LAWS ch. 12, § 11I 1/2(b); MINN. STAT. § 260.925; N.J. Exec. Order 

No. 326 (2023); N.M. STAT. § 24-34-3; N.Y. EDUC. LAW § 6531-b(2); OR. REV.

STAT. § 414.769(3); VT. STAT. tit. 15, § 1152(a); WASH. REV. CODE

§§ 7.115.020, .040. 

In March of this year, England’s National Health Service announced it 

would limit the use of puberty suppressing hormones for children, concluding 

that “there is not enough evidence to support the safety or clinical effectiveness 

of [puberty suppressing hormones] to make the treatment routinely available 

at this time.” NHS ENGLAND, CLINICAL POLICY: PUBERTY SUPPRESSING 

HORMONES (PSH) FOR CHILDREN AND YOUNG PEOPLE WHO HAVE GENDER 

INCONGRUENCE/GENDER DYSPHORIA 3 (Mar. 12, 2024). And the health 

agencies in at least four other European nations have recently revised their 

health policies to restrict hormone treatments for children. See Azeen 

Ghorayshi, Youth Gender Medications Limited in England, Part of Big Shift in 

Europe, N.Y. TIMES, Apr. 9, 2024 (describing restrictions recently implemented 

or adopted in Finland, Sweden, Norway, and Denmark). 
4 

question we are called upon to answer is a distinctly legal one: whether 

plaintiffs in this case have established a probable right to relief on their 

claims that the Legislature’s prohibition of certain treatments for 

children suffering from gender dysphoria violates the Texas 

Constitution. 

We conclude that plaintiffs failed to meet that burden. We have 

said—and we reaffirm today—that fit parents have a fundamental 

interest in directing the care, custody, and control of their children free 

from government interference. But we have never defined the source or 

precise scope of this interest, and our precedents make clear that this 

interest is not absolute. Indeed, we have never held that a fit parent’s 

interest in caring for her child free from government interference, 

though weighty, triggers heightened scrutiny of every statute that 

restricts any asserted right connected to that interest. When 

developments in our society raise new and previously unconsidered 

questions about the appropriate line between parental autonomy on the 

one hand and the Legislature’s authority to regulate the practice of 

medicine on the other, our Constitution does not render the Legislature 

powerless to provide answers. 

For the reasons explained below, we conclude the Legislature 

made a permissible, rational policy choice to limit the types of available 

medical procedures for children, particularly in light of the relative 

nascency of both gender dysphoria and its various modes of treatment 

and the Legislature’s express constitutional authority to regulate the 

practice of medicine. We therefore conclude the statute does not 

unconstitutionally deprive parents of their rights or physicians or health 
5 

care providers of an alleged property right in their medical licenses or 

claimed right to occupational freedom. We also conclude the law does 

not unconstitutionally deny or abridge equality under the law because 

of sex or any other characteristic asserted by plaintiffs. We therefore 

reverse and vacate the trial court’s order. 

I. Background 

In 2023, the Legislature enacted Senate Bill 14, captioned a 

statute “relating to prohibitions on the provision to certain children of 

procedures and treatments for gender transitioning, gender 

reassignment, or gender dysphoria.” Act of May 17, 2023, 88th Leg., 

R.S., ch. 335.3 S.B. 14 primarily modifies Chapter 161 of the Health and 

Safety Code by adding a new Subchapter X addressing “Gender 

Transitioning and Gender Reassignment Procedures and Treatments 

for Certain Children.” Id. § 2. The statute prohibits a physician4 or 

health care provider5 from performing certain actions on a child6 when 

those actions are performed for one of two purposes: (1) “transitioning a 

3 S.B. 14 received roughly sixty percent approval in both chambers of 

the Legislature. See Act of May 17, 2023 (noting that the bill was approved in 

the Senate by a vote of 19–12 and in the House by a vote of 87–56 with two 

present members not voting). It was signed by the Governor on June 2 and 

took effect on September 1, 2023. Id. § 9. 

4 “Physician” is defined as “a person licensed to practice medicine in this 

state.” TEX. HEALTH & SAFETY CODE § 161.701(4). 

5 “Health care provider” is defined as “a person other than a physician 

who is licensed, certified, or otherwise authorized by this state’s laws to provide 

or render health care or to dispense or prescribe a prescription drug in the 

ordinary course of business or practice of a profession.” TEX. HEALTH & SAFETY 

CODE § 161.701(2). 

6 “Child” is defined as “an individual who is younger than 18 years of 

age.” TEX. HEALTH & SAFETY CODE § 161.701(1). 
6 

child’s biological sex as determined by the sex organs, chromosomes, and 

endogenous profiles of the child”; or (2) “affirming the child’s perception 

of the child’s sex if that perception is inconsistent with the child’s 

biological sex.” TEX. HEALTH & SAFETY CODE § 161.702. The statute 

identifies three forms of prohibited surgical intervention: (1) “a surgery 

that sterilizes the child”; (2) “a mastectomy”; and (3) removal of “any 

otherwise healthy or non-diseased body part or tissue.” Id. § 161.702(1), 

(2), (4). The statute also prohibits providing, prescribing, administering, 

or dispensing the following prescription drugs: (1) “puberty suppression 

or blocking prescription drugs to stop or delay normal puberty”; 

(2) “supraphysiologic doses of testosterone to females”; and 

(3) “supraphysiologic doses of estrogen to males.” Id. § 161.702(3).7

There are two exceptions. First, “with the consent of the child’s 

parent or legal guardian,” the prohibitions in Section 161.702 do not 

apply to (1) prescription drugs that suppress or block puberty “for the 

purpose of normalizing puberty for a minor experiencing precocious 

puberty” or (2) “appropriate and medically necessary procedures or 

treatments” for a child that either “is born with a medically verifiable 

genetic disorder of sex development” or “does not have the normal sex 

chromosome structure for male or female as determined by a physician 

through genetic testing.” Id. § 161.703(a). Second, the statute’s 

prohibition against certain prescription drugs does not apply if that drug 

is “part of a continuing course of treatment that the child began before 

7 “Supraphysiologic” means “greater than normally present in the 

body.” Supraphysiological, MERRIAM-WEBSTER ONLINE DICTIONARY, https:// 

www.merriam-webster.com/medical/supraphysiologic. 
7 

June 1, 2023,” and “the child attended 12 or more sessions of mental 

health counseling or psychotherapy during a period of at least six 

months” before treatment began. Id. § 161.703(b). However, the statute 

limits this second exception: the child “shall wean off the prescription 

drug over a period of time and in a manner that is safe and medically 

appropriate and that minimizes the risk of complications,” and the child 

may not switch to another prohibited prescription drug or treatment. 

Id. § 161.703(c). 

S.B. 14 also amends Section 164.052(a) of the Occupations Code 

to add violations of Health and Safety Code Section 161.702 to a list of 

over twenty “prohibited practice[s]” by a physician. See TEX. OCC. CODE

§ 164.052(a)(24). And it adds Occupations Code Section 164.0552, which 

requires the Texas Medical Board to revoke a physician’s “license or 

other authorization to practice medicine” for violating Section 161.702. 

Id. § 164.0552(a). The statute expressly makes both changes to the 

Occupations Code applicable only to conduct that occurs on or after 

S.B. 14’s effective date. See Act of May 17, 2023, § 6. Finally, the statute 

provides that a state-provided child health plan for low-income, 

uninsured children under Chapter 62 of the Health and Safety Code may 

not provide coverage for the services prohibited by Section 161.702. See

TEX. HEALTH & SAFETY CODE § 62.151(g). 

A few weeks before S.B. 14 took effect, several plaintiffs sued in 

Travis County District Court, seeking a declaration that the statute is 

“unconstitutional, void, and unenforceable in its entirety.” They also 

sought temporary and permanent injunctions prohibiting the statute’s 

implementation or enforcement. 
8 

Among the plaintiffs are the parents of five children between the 

ages of nine and sixteen. Each alleges that his or her child has been 

diagnosed with gender dysphoria and, in consultation with a physician, 

either started or planned to start a course of treatment prohibited by the 

statute, as follows: 

 Luna Loe,8 age twelve, and Samantha Soe, age fifteen, had 

been taking puberty blockers before S.B. 14 took effect. 

 Nathan Noe, age sixteen, and Grayson Goe, age fifteen, had 

been taking testosterone, and Samantha had been taking 

estradiol.9

 Maeve Moe, age nine, intends to take puberty blockers when 

she reaches puberty. 

Three licensed Texas physicians—Dr. Richard Ogdon Roberts III, 

Dr. David L. Paul, and Dr. Patrick W. O’Malley—are also plaintiffs. 

They allege that, but for S.B. 14, they would continue to treat their 

underage gender dysphoria patients by performing the procedures and 

treatments the statute prohibits if called for by the generally accepted 

standard of care. The remaining plaintiffs are two organizations that 

advocate for LGBTQ+ rights: PFLAG, Inc.; and the American 

Association of Physicians for Human Rights, Inc. d/b/a GLMA. 

The defendants in this suit are the State of Texas; the Office of 

the Attorney General; Ken Paxton, in his official capacity as Attorney 

8 By agreement of the parties, the minor plaintiffs and their parents 

were permitted to proceed in all public filings under pseudonyms. 

9 Testosterone is a hormone that stimulates development of male sex 

characteristics, and estradiol is an estrogen hormone that stimulates 

development of female sex characteristics. 
9 

General10; the Texas Medical Board; and the Texas Health and Human 

Services Commission. They jointly filed a plea to the jurisdiction and a 

response to plaintiffs’ application for a temporary injunction, arguing, 

among other things, that plaintiffs’ constitutional claims were facially 

invalid. 

The trial court conducted a two-day evidentiary hearing. 

Following the hearing, it entered a temporary injunction immediately 

enjoining all defendants from enforcing S.B. 14, based on the following 

findings: 

(1) the statute “likely violates Article I, Section 19 of the Texas 

Constitution by infringing upon the fundamental right of 

parents to make decisions concerning the care, custody, and 

control of their children”; 

(2) the statute “likely violates Article I, Section 19 of the Texas 

Constitution by infringing upon Texas physicians’ right of 

occupational freedom”; and 

(3) the statute “likely violates Article I, Sections 3 and 3a [of] the 

Texas Constitution by discriminating against transgender 

adolescents with gender dysphoria because of their sex, sex 

stereotypes, and transgender status.” 

Because the trial court granted a temporary injunction based on 

its conclusion that S.B. 14 likely violates the Texas Constitution, 

defendants appealed the order directly to this Court. See TEX. GOV’T 

10 At the time suit was filed, John Scott was serving as Provisional 

Attorney General during Ken Paxton’s mandatory suspension from office. See

TEX. CONST. art. XV, § 5. Plaintiffs’ suit originally named Scott in his official 

capacity as Provisional Attorney General. By the time the temporary 

injunction was issued, Scott had been replaced as Provisional Attorney General 

by Angela Colmenero. While this appeal was pending, Paxton was reinstated 

as Attorney General. 
10 

CODE § 22.001(c) (“An appeal may be taken directly to the supreme court 

from an order of a trial court granting or denying an interlocutory or 

permanent injunction on the ground of the constitutionality of a statute 

of this state.”). We noted probable jurisdiction and set the appeal for 

oral argument. 

II. Standing 

We begin by evaluating our jurisdiction. See Tex. Propane Gas 

Ass’n v. City of Houston, 622 S.W.3d 791, 797 (Tex. 2021) 

(“[S]ubject-matter jurisdiction must exist before we can consider the 

merits, . . . and ‘we have an obligation to examine our jurisdiction any 

time it is in doubt.’” (quoting Pike v. Tex. EMC Mgmt., LLC, 610 S.W.3d 

763, 774 (Tex. 2020))). If plaintiffs lack standing to assert their claim, a 

“court has no jurisdiction over [the] claim.” DaimlerChrysler Corp. v. 

Inman, 252 S.W.3d 299, 304 (Tex. 2008). But we need not undertake a 

plaintiff-by-plaintiff analysis on the question because the existence of 

one plaintiff with standing is sufficient to confer jurisdiction in suits 

seeking to enjoin enforcement of a law. See State v. Zurawski, ___ 

S.W.3d ___, 2024 WL 2787913, at *6 (Tex. May 31, 2024). 

The first set of plaintiffs are parents suing individually and on 

behalf of their children. They allege S.B. 14 infringes on their right to 

make medical decisions for their children and unconstitutionally 

discriminates against their children for being transgender. At least 

some of these parents allege that their children were previously 

receiving treatments that the statute now prohibits and that they would 

resume those treatments if this suit were successful. Defendants do not 

argue that these parents have not alleged an injury in fact or that the 
11 

relief they seek would not provide redress. Whatever their claims’ 

ultimate merits, the parents have concretely alleged that S.B. 14 

prevents them and their children from engaging in constitutionally 

protected conduct they would continue to engage in but for the statute. 

Those allegations are sufficient to establish those parents’ standing. See

Tex. Bd. of Chiropractic Exam’rs v. Tex. Med. Ass’n, 616 S.W.3d 558, 567 

(Tex. 2021) (“Constitutional standing requires a concrete injury that is 

both traceable to the defendant’s conduct and redressable by court 

order.”). 

The plaintiffs also include physicians who allege they have 

previously prescribed or administered treatments that S.B. 14 now 

prohibits and would continue to do so but for the statute. Defendants 

assert these physicians lack standing to assert their patients’ claims. 

We need not address that issue because we conclude these physicians 

have standing to press their own claims—that S.B. 14 infringes on their 

claimed right to occupational freedom. And because the plaintiff 

parents and physicians, together, have standing to assert each of the 

three alleged constitutional violations, we can proceed to the merits with 

our jurisdiction secure and without addressing whether the plaintiff 

organizations also have standing. 

III. Are plaintiffs entitled to a temporary injunction? 

To obtain a temporary injunction, the applicant must plead and 

prove (1) a cause of action against the defendant; (2) a probable right to 

the relief sought; and (3) a probable, imminent, and irreparable injury 

in the interim. Butnaru v. Ford Motor Co., 84 S.W.3d 198, 204 (Tex. 

2002). The Court reviews an order granting a temporary injunction for 
12 

an abuse of discretion. Tex. Educ. Agency v. Hous. Indep. Sch. Dist., 660 

S.W.3d 108, 116 (Tex. 2023). Under this standard, we defer to the trial 

court’s factual findings if they are supported by the evidence, but we 

review legal determinations de novo. Haedge v. Cent. Tex. Cattlemen’s 

Ass’n, 603 S.W.3d 824, 827 (Tex. 2020). 

Here, plaintiffs make a facial challenge to the constitutionality of 

S.B. 14, seeking a declaration that it is unconstitutional “in its entirety.” 

The ultimate question of whether a statute violates the Constitution is 

a question of law. Mayhew v. Town of Sunnyvale, 964 S.W.2d 922, 932 

(Tex. 1998).11

When a party challenges the constitutionality of a statute, we 

begin with a strong presumption that the statute is valid. See Hegar v. 

Tex. Small Tobacco Coal., 496 S.W.3d 778, 785 (Tex. 2016) (“[A] 

challenged statute is entitled to a ‘strong presumption’ of constitutional 

validity.” (quoting Vinson v. Burgess, 773 S.W.2d 263, 266 (Tex. 1989))); 

Patel v. Tex. Dep’t of Licensing & Regul., 469 S.W.3d 69, 87 (Tex. 2015) 

(“[S]tatutes are presumed to be constitutional.”); Tex. State Bd. of 

Barber Exam’rs v. Beaumont Barber Coll., Inc., 454 S.W.2d 729, 732 

(Tex. 1970) (“Legislative enactments will not be held unconstitutional 

and invalid unless it is absolutely necessary to so hold.”); Smith v. Davis, 

426 S.W.2d 827, 831 (Tex. 1968) (“It is to be presumed that the 

Legislature has not acted unreasonably or arbitrarily; and a mere 

difference of opinion, where reasonable minds could differ, is not a 

11 Although the trial court labeled as “findings” its conclusions that 

S.B. 14 likely violates the Constitution, we are not bound by this designation 

with respect to applying the appropriate standard of review. Tex. Outfitters 

Ltd., LLC v. Nicholson, 572 S.W.3d 647, 653 n.7 (Tex. 2019). 
13 

sufficient basis for striking down legislation as arbitrary or 

unreasonable. The wisdom or expediency of the law is the Legislature’s 

prerogative, not ours.”). 

As in the trial court, plaintiffs here assert that S.B. 14 is facially 

unconstitutional for three reasons: (1) it infringes on the fundamental 

rights of parents to make decisions concerning the care of their children 

in violation of Article I, Section 19 (the Due Course of Law Clause); (2) it 

deprives Texas physicians of a vested property interest in their medical 

licenses and infringes on the occupational freedoms of Texas healthcare 

providers in violation of the Due Course of Law Clause; and (3) it 

discriminates against transgender children and their parents because of 

sex and transgender status in violation of Article I, Section 3 (the Equal 

Protection Clause) and Article I, Section 3a (the Equal Rights 

Amendment). The trial court concluded that plaintiffs established a 

probable right to relief on all three constitutional challenges. We 

address each of these theories in turn. 

A. Does the statute unconstitutionally infringe on 

parents’ ability to make medical decisions for their 

children? 

First, the trial court concluded the statute likely violates the Due 

Course of Law Clause “by infringing upon the fundamental right of 

parents to make decisions concerning the care, custody, and control of 

their children.” According to the trial court, this right includes the right 

of parents “to give, withhold, and withdraw consent to medical 

treatment for their children” as well as “to seek and to follow medical 

advice to protect the health and wellbeing of their minor children.” 
14 

1. Applicable law 

The Texas Constitution provides that “[n]o citizen of this State 

shall be deprived of life, liberty, property, privileges or immunities, or in 

any manner disfranchised, except by the due course of the law of the 

land.” TEX. CONST. art. I, § 19. We have adopted a two-step inquiry to 

determine whether a government action violates our Constitution’s 

guarantee of “due course of the law.” See Tex. S. Univ. v. Villarreal, 620 

S.W.3d 899, 905 (Tex. 2021) (citing Univ. of Tex. Med. Sch. at Hous. v. 

Than, 901 S.W.2d 926, 929 (Tex. 1995)). First, we consider whether the 

plaintiff has a liberty, property, or other enumerated interest that is 

entitled to protection. Id. Second, if a protected interest is implicated, 

we consider whether the defendant followed due course of law in 

depriving the plaintiff of that interest. Id. This inquiry requires a 

careful analysis of the interest of which the plaintiff is allegedly being 

deprived. See id. (noting that a constitutional challenge to a student’s 

dismissal for poor academic performance requires courts to focus on 

whether the dismissal “interferes with the student’s liberty interest in 

his or her reputation and employability, not on whether education is a 

protected liberty interest”); see also Washington v. Glucksberg, 521 U.S. 

702, 721 (1997) (stating that the U.S. Supreme Court requires a “careful 

description” of the asserted fundamental liberty interest (quoting Reno 

v. Flores, 507 U.S. 292, 302 (1993))). 

If there is no deprivation of a constitutionally protected interest, 

then a statute satisfies the Due Course of Law Clause as long as it is 

rationally related to a legitimate state purpose. See Barshop v. Medina 
15 

Cnty. Underground Water Conservation Dist., 925 S.W.2d 618, 633 (Tex. 

1996).

This Court has repeatedly recognized that parents have a 

fundamental interest in making decisions regarding the care, custody, 

and control of their children. A half century ago, we recognized that this 

“natural right” between parents and children is “one of constitutional 

dimensions.” Wiley v. Spratlan, 543 S.W.2d 349, 352 (Tex. 1976). We 

thus held that when the State seeks a parental termination order or 

other action that “permanently sunders those ties,” those proceedings 

should be “strictly scrutinized.” Id.; see also Holick v. Smith, 685 S.W.2d 

18, 20 (Tex. 1985) (“[T]ermination proceedings should be strictly 

scrutinized, and involuntary termination statutes are strictly construed 

in favor of the parent.”). 

Similarly, we have recognized that nonparents may not be 

afforded rights of possession or other rights concerning a child’s care 

without first overcoming the presumption that a fit parent acts in the 

child’s best interests. Quoting the U.S. Supreme Court’s plurality 

opinion in Troxel v. Granville, we stated, “[S]o long as a parent 

adequately cares for his or her children (i.e., is fit), there will normally 

be no reason for the State to inject itself into the private realm of the 

family . . . .” In re Mays-Hooper, 189 S.W.3d 777, 778 (Tex. 2006) 

(alteration in original) (quoting Troxel v. Granville, 530 U.S. 57, 68 

(2000) (plurality op.)). Plaintiffs point to these cases to support their 

assertion that the statute unconstitutionally infringes on what should 

be an unfettered right of parents to exercise absolute control over 

decisions regarding a child’s medical treatment. 
16 

Plaintiffs’ argument has some force, but only up to a point. 

Parents’ right to exercise control over decision-making for their children 

has limits: “the rights of natural parents are not absolute.” In re J.W.T., 

872 S.W.2d 189, 195 (Tex. 1994); see also DeWitt v. Brooks, 182 S.W.2d 

687, 690 (Tex. 1944) (“While ordinarily the natural parents are entitled 

to the custody and care of their child, this is not an absolute 

unconditional right.”). 

Of significance here, we have never questioned the Legislature’s 

constitutional authority to regulate medical treatments—including by 

prohibiting certain treatments outright—for both adults and children. 

See TEX. CONST. art. XVI, § 31 (“The Legislature may pass laws 

prescribing the qualifications of practitioners of medicine in this State 

. . . .”); Martinez v. Tex. State Bd. of Med. Exam’rs, 476 S.W.2d 400, 405 

(Tex. App.—San Antonio 1972, writ ref’d n.r.e.) (“[T]he Legislature was 

expressly granted the constitutional authority to regulate the practice 

of medicine.”); Kelley v. Tex. State Bd. of Med. Exam’rs, 467 S.W.2d 539, 

546 (Tex. App.—Fort Worth 1971, writ ref’d n.r.e.) (“It is the right and 

duty of the State to regulate and control medical practice, so that the 

public safety and welfare will be served and promoted.”). Indeed, state 

legislatures have long played a critical and recognized role in regulating 

health and welfare, which is why those efforts receive “a strong 

presumption of validity.” L.W. v. Skrmetti, 83 F.4th 460, 473 (6th Cir. 

2023) (quoting Heller v. Doe, 509 U.S. 312, 319 (1993)), cert. granted, 

2024 WL 3089532 (U.S. June 24, 2024) (No. 23-477); see also Gonzales 

v. Carhart, 550 U.S. 124, 157 (2007) (“Under our precedents it is clear 

the State has a significant role to play in regulating the medical 
17 

profession.”); Garcia v. Tex. State Bd. of Med. Exam’rs, 384 F. Supp. 434, 

437 (W.D. Tex. 1974) (three-judge panel) (“This right of a State to 

regulate under its police powers all aspects of the practice of medicine 

and thereby help provide for the general health and welfare of its 

citizens is of such vast importance as to approach the status of a duty.”), 

aff’d, 421 U.S. 995 (1975). In short, our precedents acknowledge that 

parental rights, though weighty, at times give way to other competing 

interests such as the interest in protecting children from harm. This is 

underscored by our Constitution’s express authorization of legislative 

regulation of the practice of medicine. Thus, to the extent parents 

possess a fundamental interest in obtaining medical care for their 

children, it has extended only to those medical treatments that are 

legally available. 

2. Analysis 

We conclude that the parent plaintiffs failed to establish a 

probable right to relief on their claim that the statute unconstitutionally 

deprives them of a protected interest. When analyzing a challenge 

under the Due Course of Law Clause, we first determine whether the 

plaintiff has identified a “liberty, property, or other enumerated 

interest” that is entitled to protection. Villarreal, 620 S.W.3d at 905. 

We then examine whether the State “depriv[ed]” the plaintiff of that 

interest and, if so, whether it failed to follow due course of law in doing 

so. Id.

Glucksberg provides a useful guide. In that case, the plaintiffs 

sued for a declaration that a Washington statute prohibiting assisted 

suicide was unconstitutional under the Due Process Clause of the 
18 

Fourteenth Amendment. 521 U.S. at 707–08. In concluding that the 

statute was constitutional, the Supreme Court’s analysis focused on 

whether “the asserted ‘right’ to assistance in committing suicide” is a 

fundamental liberty interest protected by the U.S. Constitution. Id. at 

728. The Court rejected an approach that would have defined the 

asserted right more broadly as a natural extension of “abstract concepts 

of personal autonomy.” Id. at 725. Plaintiffs here (and the dissent) 

likewise seek to define the asserted right as nothing more than an 

extension of “parental autonomy.” The Glucksberg Court explained the 

Constitution requires a carefully circumscribed description of the 

asserted right or liberty interest at issue: 

By extending constitutional protection to an asserted right 

or liberty interest, we, to a great extent, place the matter 

outside the arena of public debate and legislative action. 

We must therefore exercise the utmost care whenever we 

are asked to break new ground in this field, lest the liberty 

protected by the Due Process Clause be subtly transformed 

into the policy preferences of the Members of this Court. 

Id. at 720 (citations and internal quotation marks omitted). 

The Supreme Court has “regularly observed that the Due Process 

Clause specially protects those fundamental rights and liberties which 

are, objectively, deeply rooted in this Nation’s history and tradition, and 

implicit in the concept of ordered liberty, such that neither liberty nor 

justice would exist if they were sacrificed.” Id. at 720–21 (citations and 

internal quotation marks omitted). We apply a similar analysis in 

reviewing plaintiffs’ claim that S.B. 14 deprives them of a 

constitutionally protected right. See Tex. Dep’t of State Health Servs. v. 

Crown Distrib. LLC, 647 S.W.3d 648, 656 (Tex. 2022) (“[W]e should 
19 

define the interest as specifically as necessary to accurately reflect the 

constitution’s language (‘liberty’ and ‘property’), our precedential 

construction of that language, and the realities of the deprivation the 

[plaintiffs] are claiming.”). 

Plaintiffs assert that S.B. 14 violates the Due Course of Law 

Clause by infringing on parents’ “fundamental autonomy right to make 

decisions about their children’s care, including directing their medical 

care.” We have previously described “[p]arental control and autonomy” 

as a “fundamental liberty interest.” In re Scheller, 325 S.W.3d 640, 644 

(Tex. 2010) (quoting In re Derzapf, 219 S.W.3d 327, 335 (Tex. 2007) 

(quoting Troxel, 530 U.S. at 65)). Indeed, we have described the “natural 

right” between parents and their children as one “of constitutional 

dimensions.” Wiley, 543 S.W.2d at 352. Certainly, then, when the State 

seeks to sever the parent–child relationship, those proceedings must be 

“strictly scrutinized.” Id.

But neither our society’s history and legal traditions nor this 

Court’s precedents support a view of the scope of parents’ 

constitutionally protected interest in directing their children’s care, 

custody, and control that would place any action a parent may 

undertake outside the government’s authority to regulate. See J.W.T., 

872 S.W.2d at 195; DeWitt, 182 S.W.2d at 690. This plays out in various 

contexts, many of which are deeply embedded in our legal history. Some 

longstanding restrictions on children’s activities, like prohibiting child 

labor and access to tattoos and tobacco, limit parental authority. See

TEX. LAB. CODE § 51.011 (prohibiting the employment of a child younger 

than fourteen except under limited circumstances); TEX. HEALTH &
20 

SAFETY CODE § 146.012(a)(1), (a-1) (prohibiting a child younger than 

eighteen from obtaining a tattoo, even with parental consent, except to 

cover certain other tattoos or markings); id. § 161.082(a) (prohibiting the 

giving or selling of cigarettes or tobacco products to someone younger 

than twenty-one). Tattoos provide a particularly apt example, as they 

involve what is in most cases a permanent adjustment to the human 

body that is not intended to restore the body’s physical condition but 

instead applied for psychological reasons. The Legislature prohibits 

children from being tattooed, even with their parents’ consent, both 

because children may not fully appreciate the consequences of their 

actions and because of the risk that parents may be imposing their own 

desires, however well-meaning, on the child. 

Whatever the context in which they arise, these examples 

demonstrate that, while parents have a large degree of control and 

authority to decide what is best for their children, parental control and 

authority have never been understood as constitutionally mandated 

absolutes. Said differently, a fit parent’s fundamental interest in caring 

for her child free from government interference extends to choosing from 

among legally available medical treatments, but it never has been 

understood to permit a parent to demand medical treatment that is not 

legally available. The U.S. Supreme Court cases on which our Court 

relied in recognizing the “constitutional dimensions” of parental rights 

likewise acknowledged that the scope of parental authority has always 

had limits. See, e.g., Wisconsin v. Yoder, 406 U.S. 205, 220 (1972) (“It is 

true that activities of individuals, even when religiously based, are often 
21 

subject to regulation by the States in the exercise of their undoubted 

power to promote the health, safety, and general welfare . . . .”). 

Carefully described, the purported right for which plaintiffs seek 

constitutional protection is the right of parents to allow their children 

access to relatively new medical procedures and treatments for a 

relatively newly defined medical condition. Plaintiffs claim this 

asserted right is merely a part of their constitutionally recognized 

interest in “parental autonomy.” But just as the U.S. Supreme Court 

did in Glucksberg, and the Sixth Circuit recently did in a case nearly 

identical to this one, we decline the invitation to extend constitutional 

protection to a claimed right—thus placing it “outside the arena of public 

debate and legislative action”—merely because the conduct, were it 

allowed, would entail the exercise of parental judgment or 

decision-making. 521 U.S. at 720; see Skrmetti, 83 F.4th at 475 

(“[C]laimants overstate the parental right by climbing up the ladder of 

generality to a perch—in which parents control all drug and other 

medical treatments for their children—that the case law and our 

traditions simply do not support.”). 

Plaintiffs’ argument is particularly weak in the context of medical 

care, as the Legislature has express constitutional authority to regulate 

the practice of medicine. TEX. CONST. art. XVI, § 31. If it may exercise 

that authority to regulate the practice of medicine and available 

treatments for adults, it surely must be true that it may do the same for 

treatments for children. Nor is there support for the idea that regulation 

of children’s medical treatments would be more closely scrutinized than 
22 

regulation of medical treatments for adults because children’s medical 

treatments usually require parental consent on the child’s behalf. 

Our dissenting colleague places much weight on Parham v. J. R., 

442 U.S. 584 (1979), which involved a procedural due process claim and 

does not support a conclusion that parents’ fundamental interest in their 

children’s care includes a right to obtain any medical treatment for 

them, such as those at issue here. The issue in Parham was whether a 

state statute that allowed parents to commit their children to a 

psychiatric hospital unconstitutionally deprived the children of 

procedural due process because there was no formal hearing before they 

were committed. See id. at 596–97. In concluding the statute passed 

constitutional muster, the Court considered the children’s liberty 

interest in freedom from confinement together with the interests of the 

parents and the State. Id. at 600–06. The Court noted that parents 

generally have “broad parental authority” over their children as well as 

a “high duty” to seek and follow medical advice. Id. at 602. And it 

acknowledged the presumption that parents act in their children’s best 

interests, though it noted that presumption can be rebutted. Id. But 

nothing in the Court’s opinion suggests that it was recognizing a 

substantive constitutional right for parents to obtain novel medical care 

for their children. See Cruzan v. Dir., Mo. Dep’t of Health, 497 U.S. 261, 

286 (1990) (“[P]etitioners would seek to turn a decision [Parham] which 

allowed a State to rely on family decisionmaking into a constitutional 

requirement that the State recognize such decisionmaking. But 

constitutional law does not work that way.”). As the Sixth Circuit 

concluded, “[t]his traditional due process ruling does not support today’s 
23 

untraditional request for relief under substantive due process.” 

Skrmetti, 83 F.4th at 476–77.12

We need not and do not hold that the Legislature could withdraw 

from parents the authority to choose any legal, available medical 

treatment. Rather, we hold only that novel treatments for a novel 

condition are generally within the Legislature’s power to regulate 

without facing heightened scrutiny. See Kansas v. Hendricks, 521 U.S. 

346, 360 n.3 (1997) (“[W]hen a legislature ‘undertakes to act in areas 

fraught with medical and scientific uncertainties, legislative options 

must be especially broad and courts should be cautious not to rewrite 

legislation.’” (quoting Jones v. United States, 463 U.S. 354, 370 (1983))). 

Plaintiffs’ expert testified that the first use of puberty blockers for 

children with gender dysphoria was in Europe in the 1990s, and the 

earliest identified study regarding the effectiveness and risks of the 

treatments at issue here was published in 2009. Whatever the precise 

contours of the fundamental liberty interest held by parents, the notion 

that it includes a right to pursue the treatments at issue here is not 

“deeply rooted in our history and traditions.” Glucksberg, 521 U.S. at 

727; see also Skrmetti, 83 F.4th at 475 (“This country does not have a 

custom of permitting parents to obtain banned medical treatments for 

their children and to override contrary legislative policy judgments in 

12 In rejecting the dissenters’ argument that only an adversarial hearing 

could protect the children’s procedural due process rights, the Parham Court 

criticized them for “[r]elying on general statements from past decisions dealing 

with governmental actions not even remotely similar to those involved here.” 

442 U.S. at 608 n.16. The dissent here likewise relies on general statements 

regarding parental autonomy in unrelated contexts to support its one-size-fitsall approach to reviewing the Legislature’s actions. 
24 

the process.”); Eknes-Tucker v. Governor, 80 F.4th 1205, 1224 (11th Cir. 

2023) (“[N]one of the binding decisions regarding substantive due 

process establishes that there is a fundamental right to treat one’s 

children with transitioning medications subject to medically accepted 

standards.” (alteration and internal quotation marks omitted)); Abigail 

All. for Better Access to Developmental Drugs v. von Eschenbach, 495 

F.3d 695, 710 & n.18 (D.C. Cir. 2007) (en banc) (identifying multiple 

courts that have “rejected arguments that the Constitution provides an 

affirmative right of access to particular medical treatments reasonably 

prohibited by the Government”). Moreover, the contours of a 

constitutional right do not turn on plaintiffs’ assertion that a particular 

treatment is currently “recognized by the medical community.” See

Jones, 463 U.S. at 364 n.13 (“We do not agree with the suggestion that 

Congress’ power to legislate in this area depends on the research 

conducted by the psychiatric community.”); Eknes-Tucker, 80 F.4th at 

1224 (“[T]hose decisions applying the fundamental parental right in the 

context of medical decision-making do not establish that parents have a 

derivative fundamental right to obtain a particular medical treatment 

for their children as long as a critical mass of medical professionals 

approve.”).13

13 The dissent describes the medical treatments at issue as the product 

of “well-established industry standards.” Post at 11 (Lehrmann, J., 

dissenting). It relies heavily on standards of care promulgated less than two 

years ago by the World Professional Association for Transgender Health 

(WPATH), an organization whose mission includes “advocacy that affects the 

lives of [transgender and gender diverse] people.” E. Coleman et al., Standards 

of Care for the Health of Transgender and Gender Diverse People, Version 8, 

INT’L J. TRANSGENDER HEALTH S1, S5 (2022). Although WPATH had 
25 

While S.B. 14 limits the availability of novel medical treatments 

for children diagnosed with a novel medical condition, it does not deprive 

those children’s parents of any constitutionally protected right or 

undermine a custom embedded in our history or traditions. The statute 

does not sever parents’ control or autonomy to make medical decisions 

for their children, nor does it displace a child’s parent as the ultimate 

decision maker. The law merely restricts the availability of new 

treatments with which medical providers may treat children diagnosed 

with a newly defined medical condition, gender dysphoria. It therefore 

previously issued standards of care for treatment of transgender individuals, 

it describes its 2022 standards as “the first to be developed using an 

evidence-based approach.” WPATH, SOC8 History and Purpose 1.3, https:// 

www.wpath.org/soc8/history (last visited June 26, 2024). In issuing its 2022 

standards, however, WPATH “note[d] the paucity of research supporting the 

long-term effectiveness of medical treatment for adolescents with gender 

dysphoria.” Chad Terhune et al., As more transgender children seek medical 

care, families confront many unknowns, REUTERS, Oct. 6, 2022, 

https://reuters.com/investigates/special-report/usa-transyouth-care/; see also

Coleman, supra, at S46 (“[A] systematic review regarding outcomes of 

treatment in adolescents is not possible.”). Earlier this year, a series of leaked 

internal communications revealed that “the provision of so-called 

gender-affirming care is riddled with far more doubt than WPATH’s message 

that such treatments are ‘not considered experimental’.” The WPATH files: 

Leaked conversations throw light on a controversial field of medicine, THE 

ECONOMIST, Mar. 9, 2024, at 25. 

The novelty of using medical treatments and procedures on children 

with gender dysphoria is further demonstrated by the fact that it is only within 

the last decade or so that medical organizations like the American Psychiatric 

Association and the World Health Organization moved away from 

characterizing gender dysphoria as a purely mental-health disorder. See

Transgender no longer recognised as “disorder” by WHO, BBC NEWS (May 29, 

2019), https://www.bbc.com/news/health-48448804; Traci G. Lee, Being 

transgender no longer a “mental disorder”: APA, NBC NEWS (Dec. 4, 2012) 

https://www.nbcnews.com/id/wbna50075205. 
26 

will satisfy the Due Course of Law Clause if it is rationally related to a 

legitimate state purpose. See Barshop, 925 S.W.2d at 633.14

Plaintiffs contend that the statute falls short of even this bar 

because it is “rooted in anti-transgender animus.” In support, they first 

argue that the evidence establishes that each of the prohibited 

procedures is safe, effective, and accepted in the medical community.15 

But a court’s determination regarding the ultimate correctness of the 

Legislature’s findings is not a proper basis for rejecting a statute. Owens 

Corning v. Carter, 997 S.W.2d 560, 582 (Tex. 1999); Tex. Workers’ Comp. 

Comm’n v. Garcia, 893 S.W.2d 504, 520 (Tex. 1995). Plaintiffs do not 

14 In applying this standard, we need not and do not decide whether 

every law that could be argued to infringe on a fit parent’s interest in directing 

the care, custody, and control of her child would also be subject to the same 

level of scrutiny. Whether it would depends on many factors, including (to 

name just two): (1) whether there is express constitutional authorization for or 

prohibition against the challenged law; and (2) whether the regulated conduct 

is novel or firmly supported in our history and traditions. These considerations 

are not exhaustive but merely meant to illustrate that our holding today should 

not be read to mean that one size fits all. We do not foreclose the possibility 

that a different law that could be argued to constitute an impermissible 

encroachment on a fit parent’s rights could be subject to heightened scrutiny. 

15 The dissent twice characterizes testimony from the State’s expert, Dr. 

Cantor, as an admission that his position was contrary to “the entire medical 

establishment.” Post at 15, 29 (Lehrmann, J., dissenting). Dr. Cantor was 

responding to a question pointing out that an Alabama federal district court 

judge (whose order enjoining a statute similar to Texas’s was later vacated by 

the Eleventh Circuit) gave his testimony little weight. See Eknes-Tucker v. 

Marshall, 603 F. Supp. 3d 1131, 1142–43 (M.D. Ala. 2022), rev’d sub nom.

Eknes-Tucker v. Governor, 80 F.4th 1205 (11th Cir. 2023). A fairer reading of 

his testimony is that he was theorizing that the district court judge may have 

justified minimizing his opinion by viewing it as “essentially me versus the 

entire medical establishment.” As he made clear elsewhere in his testimony, 

Dr. Cantor’s opinion is that the medical research studies do not support any 

established treatment for children with gender dysphoria, an opinion 

supported by health agencies in Europe. See Ghorayshi, supra note 2. 
27 

(and cannot) dispute that the Legislature has legitimate interests in 

both regulating medical procedures and in protecting the health and 

wellbeing of children. Accordingly, we uphold the law if it is rationally 

related to a legitimate government interest. See Owens Corning, 997 

S.W.2d at 580; Barshop, 925 S.W.2d at 633. 

Notwithstanding this Court’s or the trial court’s views, the 

Legislature had a rational basis for concluding that the risk of providing 

these treatments to children solely for the purpose of physically 

transitioning from their sex at birth was not outweighed by the benefits. 

Plaintiffs respond that the prohibition based on the Legislature’s 

perceived risk of harm to children is pretextual because the exceptions 

permit these same treatments for other medical conditions. But the 

decision to prohibit particular medical procedures for a certain condition 

is based on a balance between both risks and benefits of the treatment 

in contrast to other treatments for the same underlying condition. The 

Legislature could rationally reach different conclusions on the balance 

of risks and benefits when physical treatments are used to treat a purely 

physical condition (such as precocious puberty) as opposed to a condition 

like gender dysphoria, for which other treatment options exist. Indeed, 

policymakers in many other states, as well as other nations, have made 

similar judgments. 

Plaintiffs also cite the statute’s legislative history, focusing on 

statements by lawmakers that, they contend, demonstrate that the 

statute’s enactment was motivated by a “desire to harm transgender 
28 

adolescents.”16 The State rejects this characterization of the statements, 

but we need not decide which interpretation is correct. Even if we 

assume the legislative history demonstrates someone voting for this bill 

may have been improperly motivated, that constitutes no evidence that 

all, most, or even a significant percentage of the over 100 legislators who 

voted for the statute were similarly motivated. See Tex. Health 

Presbyterian Hosp. v. D.A., 569 S.W.3d 126, 136–37 (Tex. 2018) (“An 

individual legislator’s statements—even those of the bill’s author or 

sponsor—do not and cannot describe the understandings, intentions, or 

motives of the many other legislators who vote in favor of a bill.”). 

B. Does the statute unconstitutionally infringe on 

physicians’ property rights or medical providers’ 

occupational freedom? 

The trial court also concluded that S.B. 14 likely violates the Due 

Course of Law Clause “by infringing upon Texas physicians’ right of 

occupational freedom.” The court went on to say that the statute 

“deprives Texas physicians of a vested property interest in their medical 

licenses”; that it “interferes with the professional relationship among 

medical providers, adolescent patients, and the patients’ parents”; and 

that the statute is “clearly arbitrary and its effect as a whole is so 

unreasonably burdensome that it is oppressive.”

16 The specific statements plaintiffs identify in their pleadings are 

(1) one senator’s depictions of gender dysphoria as a “social contagion” and a 

“mental delusion” and (2) one representative’s reference to the medical 

treatment of gender dysphoria as “harmful experimentation” and comparing it 

to the opioid epidemic and the use of lobotomies to treat schizophrenia or 

depression. 
29 

1. Applicable law 

Again, the first step in our inquiry under the Due Course of Law 

Clause is to carefully define the interest of which these plaintiffs are 

allegedly being deprived. Villarreal, 620 S.W.3d at 905. If the plaintiffs 

are not deprived of a constitutionally protected interest, the statute is 

constitutional so long as it is rationally related to a legitimate state 

purpose. Barshop, 925 S.W.2d at 633. 

In Patel v. Texas Department of Licensing & Regulation, this 

Court held that an as-applied challenge to an economic regulation 

statute based on the Due Course of Law Clause “must demonstrate that 

either (1) the statute’s purpose could not arguably be rationally related 

to a legitimate governmental interest; or (2) when considered as a whole, 

the statute’s actual, real-world effect as applied to the challenging party 

could not arguably be rationally related to, or is so burdensome as to be 

oppressive in light of, the governmental interest.” 469 S.W.3d at 87. 

But, as with parental rights, a person’s protected work-related interests 

“are not without limits.” Crown Distrib., 647 S.W.3d at 654. We 

underscored the point in Crown Distributing: “[n]either ‘property rights 

nor contract rights are absolute.’” Id. (quoting Nebbia v. New York, 291 

U.S. 502, 523 (1934)). 

2. Analysis 

We conclude the physicians and healthcare providers failed to 

establish a probable right to relief on their claims under the Due Course 

of Law Clause. As with plaintiffs’ arguments regarding parental rights, 

the arguments on behalf of these plaintiffs incorrectly characterize the 
30 

scope of the constitutionally protected interest of which the statute 

allegedly deprives them. 

Plaintiffs argue that Texas physicians have a vested property 

interest in their medical licenses and that, under S.B. 14, those licenses 

“shall” be revoked if they provide prohibited medical care to children. 

See TEX. OCC. CODE § 164.0552(a). Plaintiffs therefore urge that the 

statute must be subject to strict scrutiny. We disagree. To the extent 

that a license to practice medicine can be construed as a property 

interest, that interest is subject to regulation and not absolute. Our 

Constitution expressly authorizes the Legislature to “pass laws 

prescribing the qualifications of practitioners of medicine.” TEX. CONST. 

art. XVI, § 31. In accordance with that constitutional mandate, the 

Legislature enacted the Medical Practice Act, expressly finding that “the 

practice of medicine is a privilege and not a natural right of individuals” 

and that legislative regulation of that privilege and its subsequent use 

and control “is necessary to protect the public interest.” TEX. OCC. CODE

§ 151.003(1). That authorization necessarily includes the ability to 

prohibit certain practices altogether. 

In short, a medical license does not confer on physicians a right 

to practice medicine in any way they see fit. To the extent that the 

State’s granting a medical license creates a protected property interest, 

that interest does not extend to practices that the State has determined 

to be unlawful. In other words, Texas physicians have no 

constitutionally protected interest to perform medical practices that the 

Legislature has rationally determined to be illegal. 
31 

Plaintiffs rely on House of Tobacco, Inc. v. Calvert, in which we 

described a permit authorizing the sale of tobacco products as a 

“privilege which does not have to be granted; however, once it is granted, 

it cannot be taken away except for good cause.” 394 S.W.2d 654, 657 

(Tex. 1965). We therefore held that the State Comptroller’s order 

revoking the permit was void because the permit holder was first 

entitled to notice and a hearing under the Due Course of Law Clause. 

Id. at 658. But we have never held that the granting of a medical license, 

or any license, gives the holder a substantive property right to engage 

in conduct without limitation by the Legislature. 

Plaintiffs cannot show that the statute unconstitutionally 

infringes on a protected property interest. And plaintiffs have not 

alleged that the procedural protections required to revoke a medical 

license, including notice and an opportunity to be heard, see TEX. OCC.

CODE § 164.004, the physician’s right to administrative review, see id.

§ 164.007, and the physician’s right to judicial review, see id. § 164.009, 

are constitutionally inadequate. We therefore reject plaintiffs’ Due 

Course of Law Clause claim with respect to physicians’ medical licenses. 

Plaintiffs next argue that S.B. 14 unconstitutionally infringes on 

medical providers’ liberty interest “to engage in their occupations.” They 

contend that the threat of license revocation and discipline for engaging 

in practices prohibited by the Legislature is “clearly arbitrary and so 

unreasonably burdensome that it is oppressive.” See Patel, 469 S.W.3d 

at 87 (holding that an economic-regulation statute violates the Due 

Course of Law Clause as applied to the challenging party if its effect as 

a whole is so unreasonably burdensome that it becomes oppressive in 
32 

relation to the underlying governmental interest). We need not decide 

whether the standard we announced in Patel applies here because 

plaintiffs cannot show that this statute, or any statute that limits 

particular medical treatments for children, imposes an unreasonable 

burden on physicians’ ability to practice medicine. The statute does not 

prevent medical providers from treating children with gender dysphoria 

with treatments other than those that are prohibited, nor does it 

prohibit them from providing those medical procedures to adults. 

C. Does the statute unconstitutionally deny or abridge 

equality under the law? 

Finally, the trial court concluded that S.B. 14 likely violates 

Article I, Sections 3 and 3a “by discriminating against transgender 

adolescents with gender dysphoria because of their sex, sex stereotypes, 

and transgender status.”

1. Applicable law 

Article I, Section 3 of the Texas Constitution provides the 

following guarantee of equal rights: “All freemen, when they form a 

social compact, have equal rights, and no man, or set of men, is entitled 

to exclusive separate public emoluments, or privileges, but in 

consideration of public services.” TEX. CONST. art. I, § 3. We have 

typically referred to Section 3 as our Constitution’s “equal protection” 

clause. See Bell v. Low Income Women of Tex., 95 S.W.3d 253, 257 n.4 

(Tex. 2002). In 1972, Texans adopted the Equal Rights Amendment, 

which states, “Equality under the law shall not be denied or abridged 

because of sex, race, color, creed, or national origin.” TEX. CONST. art. I, 

§ 3a. For convenience, we will refer to these two provisions jointly as 

the Equal Rights Clauses. 
33 

We evaluate alleged violations of the Equal Rights Clauses in 

three steps. Bell, 95 S.W.3d at 257 (citing In re McLean, 725 S.W.2d 

696, 697 (Tex. 1987) (plurality op.)). First, we examine whether 

“equality under the law” has been denied. Id. If it has, then we 

determine whether equality was denied because of a person’s 

membership in a protected class of sex, race, color, creed, or national 

origin. Id. (citing McLean, 725 S.W.2d at 697). If we conclude that 

equality was denied because of a person’s membership in a protected 

class, the challenged action cannot stand unless it is narrowly tailored 

to serve a compelling governmental interest. Id. (citing McLean, 725 

S.W.2d at 698). 

We have applied this framework in an analogous case, Bell. 

There, we concluded that the State’s restrictions on abortion funding did 

not deny equality “because of” sex, even though only women could 

become pregnant. Id. at 263–64. We distinguished the “overt 

gender-based distinction” of a statute we held unconstitutional in 

McLean, which imposed different burdens on fathers and mothers 

seeking the same relief. Bell, 95 S.W.3d at 258; see McLean, 725 S.W.2d 

at 697. We reasoned that the restriction in Bell was directed at abortion 

as a medical treatment, and we held that the funding scheme was not 

“merely a pretext designed to prefer males over females in the provision 

of health care.” 95 S.W.3d at 258. 

2. Analysis 

We conclude that S.B. 14 does not deny or abridge “[e]quality 

under the law” because of plaintiffs’ membership in any protected class. 

See TEX. CONST. art. I, § 3a; Bell, 95 S.W.3d at 257. Plaintiffs argue that 
34 

the statute discriminates against them because of sex, a protected class 

under the Equal Rights Clauses. They contend the statute does so in 

two ways: (1) it facially discriminates by denying certain medical 

treatments based on whether the intended recipient is male or female; 

and (2) it discriminates against transgender people, which plaintiffs 

contend “is necessarily sex discrimination.” 

With respect to plaintiffs’ first argument, under the statute, no 

person is “treated differently from others similarly situated” based on 

their sex. See Klumb v. Hous. Mun. Emps. Pension Sys., 458 S.W.3d 1, 

13 (Tex. 2015) (quoting Tex. Dep’t of Transp. v. City of Sunset Valley, 146 

S.W.3d 637, 647 (Tex. 2004)). The statute treats both males and females 

receiving treatment for gender dysphoria the same by prohibiting 

medical providers from prescribing or supplying cross-sex hormone 

therapy or other treatments that conflict with the child’s sex at birth. 

Recent decisions from the Sixth and Eleventh Circuits are in accord. See

Skrmetti, 83 F.4th at 480 (“Such an across-the-board regulation lacks 

any of the hallmarks of sex discrimination. It does not prefer one sex 

over the other.”); Eknes-Tucker, 80 F.4th at 1228 (concluding that 

Alabama’s statute “refers to sex only because the medical procedures 

that it regulates . . . are themselves sex-based” and therefore it “does not 

establish an unequal regime for males and females”). The mere fact that 

the statute identifies hormones that are prohibited for males and others 

that are prohibited for females does not deny or abridge equal treatment 

because of sex. We rejected a similar argument in Bell, concluding that 

a statutory restriction on funding for abortion as a medical treatment 
35 

did not prefer males over females in the provision of health care, even 

though only females can get pregnant. 95 S.W.3d at 258. 

Plaintiffs also argue that the statute discriminates against 

“transgender people” because it prohibits certain medical treatments 

only if those treatments are intended to transition a patient from one 

sex to another. Although they acknowledge that “transgender status” is 

not one of the protected classes enumerated in the Constitution, they 

argue that it “is necessarily sex discrimination.” Plaintiffs primarily 

rely on Bostock v. Clayton County, in which the U.S. Supreme Court held 

that firing an employee for being transgender violates Title VII’s 

statutory prohibition against “discriminat[ing] . . . because of such 

individual’s . . . sex.” 590 U.S. 644, 655, 662 (2020) (quoting 42 U.S.C. 

§ 2000e-2(a)(1)). But the Supreme Court’s interpretation of Title VII, 

which focuses on but-for discriminatory acts by individual employers, 

does not apply to the Texas Constitution’s textually distinct guarantee 

that “[e]quality under the law shall not be denied or abridged because of 

sex.” TEX. CONST. art. I, § 3a. As noted above, the prohibitions in S.B. 14 

do not treat any person differently from those in a similar situation 

because of that person’s sex. See Klumb, 458 S.W.3d at 13; Bell, 95 

S.W.3d at 258. 

Finally, plaintiffs argue that S.B. 14 “categorizes on the basis of 

an inherently suspect characteristic” and therefore should be subject to 

strict scrutiny under Article I, Section 3. See First Am. Title Ins. Co. v. 

Combs, 258 S.W.3d 627, 639 (Tex. 2008) (quoting Nordlinger v. Hahn, 

505 U.S. 1, 10 (1992)). But this Court has previously concluded that 

Section 3a “is more extensive and provides more specific protection 
36 

than” Section 3. McLean, 725 S.W.2d at 698. Since the Equal Rights 

Amendment’s adoption in 1972, this Court has never expanded the 

Equal Rights Clauses’ protection to classifications that fall outside those 

enumerated in Section 3a. We decline plaintiffs’ invitation to create a 

new protected class beyond those Texas voters have adopted. See In re 

J.C., 594 S.W.3d 466, 477 (Tex. App.—Fort Worth 2019, no pet.) 

(“[R]espect for the separation of powers should make courts reluctant to 

establish new suspect classes.” (internal quotation marks omitted) 

(quoting Thomasson v. Perry, 80 F.3d 915, 928 (4th Cir. 1996))).17

17 A divided Fourth Circuit, sitting en banc, recently concluded that 

state healthcare plans in North Carolina and West Virginia that excluded 

coverage for surgeries designed to treat gender dysphoria were subject to 

heightened (intermediate) scrutiny and were unconstitutional under the Equal 

Protection Clause of the Fourteenth Amendment. Kadel v. Folwell, 100 F.4th 

122, 155–56, 156–57 (4th Cir. 2024) (en banc). Kadel’s reasoning is 

inapplicable here. The majority concluded that the states’ restriction on 

surgeries to treat gender dysphoria necessarily discriminated based on sex or 

gender identity because “only transgender people would get” those surgeries. 

Id. at 148. This is contrary to Bell, in which we held that a restriction directed 

at a particular medical condition—pregnancy—that affected only women did 

not, for that reason, implicate our Equal Rights Clauses. Bell, 95 S.W.3d at 

258; see also Geduldig v. Aiello, 417 U.S. 484, 496 n.20 (1974) (“Absent a 

showing that distinctions involving pregnancy are mere pretexts designed to 

effect an invidious discrimination against the members of one sex or the other, 

lawmakers are constitutionally free to include or exclude pregnancy from the 

coverage of legislation . . . on any reasonable basis . . . .”). 
37 

IV. Conclusion 

Plaintiffs failed to establish a probable right to relief on any of 

their three asserted constitutional violations. We therefore reverse and 

vacate the trial court’s Temporary Injunction Order. 

 

 Rebeca A. Huddle 

 Justice 

OPINION DELIVERED: June 28, 2024