This article was first published by The 19th.
The Supreme Court on Wednesday ruled that Tennessee’s ban on gender-affirming care for transgender youth should remain in place. The court found that Tennessee’s law restricting certain medical treatments for trans minors does not violate the 14th Amendment’s equal protection clause — a finding that experts worry will set new precedent for how transgender people can be treated under the U.S. Constitution.
This 6-3 opinion, signed by Chief Justice John G. Roberts Jr., will further restrict a form of health care that has been increasingly banned for transgender youth across the country, both by Republican state lawmakers and by the Trump administration. Twenty-five states ban hormone replacement therapy and puberty blockers for trans youth, as well as surgeries, which are rare for minors; two other states ban only surgeries. Of those 25 states, six have made it a felony for medical providers to administer gender-affirming care, according to the Movement Advancement Project, which tracks LGBTQ+ policy.
Roberts wrote that “the voices in these debates raise sincere concerns; the implications for all are profound.” He emphasized, however, that the court’s role is to ensure that the law does not violate the equal protection clause. “Having concluded that it does not,” he added, “we leave questions regarding its policy to the people, their elected representatives, and the democratic process.”
Although this case impacts specifically Tennessee, the Supreme Court has now signaled that it does not plan to intervene when other states restrict medical care for trans youth. This may embolden more states to ban the care and it could also complicate ongoing lawsuits against current state bans. At least 110,000 transgender youth already live in states that restrict or limit gender-affirming care access, according to the Williams Institute at UCLA School of Law. Many families of trans kids have left these states to find health care elsewhere — and so have the doctors providing it.
Hormone replacement therapy (HRT) is used by many trans people to treat gender dysphoria, which is a strong and persistent distress felt when one’s body is out of sync with their identity. Without treatment, gender dysphoria can severely and negatively impact day-to-day life. HRT is also used to treat menopause and conditions like polycystic ovary syndrome. However, its use specifically to treat gender dysphoria in trans people, and particularly trans youth, is what has come under intense political scrutiny in the past five years.
Justice Sonia Sotomayor, one of three justices to vote against upholding Tennessee’s ban, wrote: “[The Court] authorizes, without second thought, untold harm to transgender children and the parents and families who love them. Because there is no constitutional justification for that result, I dissent.”
Opponents of gender-affirming care say that teenagers starting hormone replacement therapy — and pre-pubescent children taking puberty blockers — are too young to make these medical decisions. However, opponents often inaccurately portray the care as rushed, sloppy or even akin to mutilation. To obtain gender-affirming care, a young trans person works with their parents and doctors over the course of months or years to prove that medical intervention is right for them. Medical providers stress that there is not a “one-size-fits-all” approach and that side effects, like the risk of decreased bone density when taking puberty blockers, are closely monitored and communicated to patients.
Major medical groups including the American Medical Association, American Psychological Association and the American Academy of Pediatrics have endorsed the use of gender-affirming care for transgender youth. The new president of the World Professional Association for Transgender Health, which sets global standards for doctors and nurses providing health care to trans patients, has expressed concerns that banning gender-affirming care will simply drive the care underground and endanger patients.
The high court’s decision in this case upholds the 6th U.S. Circuit Court of Appeals’ conclusion in 2023, which allowed Tenneesse’s ban to take hold over a statewide injunction. This case began in April 2023 as L.W. v. Skrmetti, when the ACLU and Lambda Legal sued Tennessee — via the state’s attorney general, Jonathan Skrmetti — to block the state’s health care ban. Attorneys filed the lawsuit on behalf of Samantha and Brian Williams of Nashville and their teenage daughter, two other families of trans youth and Dr. Susan Lacy, a Memphis-based gynecologist providing gender-affirming care to adults and minors.
