Federally funded family planning centers in Texas must receive parental consent before prescribing birth control to teenagers, an appeals court ruled Tuesday, partially upholding a decision from a lower court.

The decision was issued by a three-judge panel from the U.S. Court of Appeals for the Fifth Circuit. It’s the highest profile legal challenge to birth control access since Roe v. Wade was overturned in June 2022, and could be appealed to the Supreme Court.

The case concerns a potential conflict between Texas and federal laws. Texas requires minors to get parental approval before receiving contraception. But these federal clinics, funded through the national Title X program, had been exempt from that requirement. That is because the federal law creating Title X did not require clinicians to get family consent, instead suggesting that they involve families “to the extent practical.” Prior to this case, federal courts had consistently found that Title X guaranteed minors the right to access birth control without parental involvement.

For decades, Texas Republicans have tried unsuccessfully to change that. This case marks their first successful attempt. 

The Fifth Circuit held that the federal law creating Title X does not trump the Texas restriction, even though federal laws are generally considered to preempt state laws if the two are in conflict. 

“Title X’s goal (encouraging family participation in teens’ receiving family planning services) is not undermined by Texas’s goal (empowering parents to consent to their teen’s receiving contraceptives),” the court’s judges wrote. “To the contrary, the two laws reinforce each other.”

In defending Title X, the federal government argued that the suit’s plaintiff — Alexander Deanda, a Texas father — did not have legal standing to challenge the Title X law, noting that Deanda could not prove one of his daughters had gotten health care at such a clinic. 

In their ruling, the Fifth Circuit held that the federal government had violated Deanda’s state-created parental right to determine what kind of medical care his children received.

In oral arguments last November, members of the panel — including Judge Stuart Kyle Duncan, who authored the ruling — expressed concern about letting minors receive birth control without parental knowledge. “If she did receive contraceptives without my knowledge, that interferes in a dramatic way with my ability to parent, because the child now has a means of engaging in sexual activity and avoiding certain consequences of it,” Duncan said at the time.

Duncan, who was appointed to the court in 2018 by former President Donald Trump, was known for his prior work in other lawsuits meant to restrict access to contraception, notably the Supreme Court case Burwell v. Hobby Lobby, which resulted in the weakening of the Affordable Care Act’s birth control coverage mandate.

The court did not address Deanda’s other argument: — that outside of Texas, the U.S. Constitution guaranteed him that right as well.

The lawsuit in Texas has meant that, since the lower court ruling in December 2022, minors seeking contraception — even at Title X clinics — could not get that care without parental consent. The judge who issued that ruling, Matthew Kacsmaryk, also previously argued that medication abortion pills should be taken off the market, in a case set to be heard by the Supreme Court this month. 

Many abortion opponents also support greater restrictions on contraception, especially intrauterine devices and the so-called morning after pill. In the months after Roe’s overturn, legal scholars suggested that states with abortion restrictions could next turn to limiting access to birth control. Such restrictions are popular with conservative lawmakers, but so far, they haven’t taken off.

The Fifth Circuit’s decision comes just as efforts are underway to broaden access to birth control. Earlier this month, pharmaceutical company Perrigo announced that its first over-the-counter hormonal birth control  — a progestin-only pill called Opill — would be available in pharmacies by the end of March, with a three-month supply costing $49.99.