Supreme Court Upholds Gender-Affirming-Care Ban. Here's What to Know

Time​ Magazine

5 hours ago

The Supreme Court has delivered a major blow to transgender rights with its decision to uphold a Tennessee law that bars doctors from providing gender-affirming care including puberty blockers, hormones, and surgical procedures for trans minors in the state.
The Wednesday decision in the landmark U.S. v. Skrmetti case is expected to upend access to healthcare for trans and nonbinary youth far beyond Tennessee. While the ruling does not ban gender-affirming care nationwide, it permits the at least 25 bans that states have passed against medical and surgical care for transgender youth. Some states, such as Florida, have similarly moved to restrict access to such care for adults.
The opinion comes as the Trump Administration targets transgender Americans on the federal level as well, seeking to bar requests for updated gender markers on federal identification documents that align with the holder's gender identity and releasing a U.S. Department of Health and Human Services report aiming to discredit gender-affirming care as treatment for individuals with gender dysphoria. The effort to bar accurate gender markers was blocked by a federal judge on Tuesday.
The Supreme Court's decision will pose a significant obstacle for legal challenges to the mounting restrictions being placed on gender-affirming care across the country.
In the ruling, the conservative majority rejected arguments that barring such care violated the equal protection clause of the 14th Amendment.
'This case carries with it the weight of fierce scientific and policy debates about the safety, efficacy, and propriety of medical treatments in an evolving field,' Chief Justice John Roberts wrote for the majority in the court's 6-3 ruling. 'The Equal Protection Clause does not resolve these disagreements.'
Here's what to know about the decision and how it will impact care.
What does the Supreme Court's decision mean for gender-affirming care?
The lawsuit at the core of the U.S. v. Skrmetti, filed by the families of three transgender adolescents and a Memphis-based medical provider, challenged the Tennessee ban on gender-affirming care for minors under the equal protection clause, citing sex discrimination.
The state of Tennessee, meanwhile, argued that the ban would help protect children from what it referred to as 'experimental' medical treatment, though every major medical and mental health association supports gender-affirming care as a legitimate health practice, per GLAAD.
The justices found that the law is a standard state regulation on medical care and does not discriminate on the basis of sex. 'The law does not prohibit certain medical treatments for minors of one sex while allowing those same treatments for minors of the opposite sex,' the majority opinion reads.
Justices Sonia Sotomayor, Ketanji Brown Jackson and Elena Kagan dissented. 'Male (but not female) adolescents can receive medicines that help them look like boys, and female (but not male) adolescents can receive medicines that help them look like girls,' Sotomayor wrote in a dissent joined in full by Jackson and in part by Kagan. 'By retreating from meaningful judicial review exactly where it matters most, the Court abandons transgender children and their families to political whims. In sadness, I dissent.'
The state of Tennessee is home to about 3,000 transgender youth, according to UCLA School of Law's Williams Institute. Nationwide, there are an estimated 300,000 transgender adolescents.
The Supreme Court's ruling will also allow gender-affirming-care bans in states beyond Tennessee to go into effect, though it does not enact a nationwide ban. That means transgender minors living in a state with a ban will have to seek care in other states in order to continue receiving medication or other gender-affirming treatments.
It is still unclear how the ruling could affect potential gender-affirming-care bans for adults, according to Alex Reinert, a constitutional law and civil rights professor at Cardozo School of Law. 'The court doesn't address that,' he says. 'But I think the reasoning that the court has provided would apply to attempts to regulate gender-affirming care for adults as well.'
Many activists are lamenting the decision due to its potential effect on transgender youth. 'The biggest human tragedy here are the trans kids whose lives are going to be irrevocably changed as a result of not being able to get the best practice healthcare that their parents want them to get, [and] that their doctors want them to get,' says Cathryn Oakley, senior director of legal policy at the Human Rights Campaign, a nonprofit advocating for LGBTQ+ rights.
A 2022 study published in the National Library of Medicine found that gender-affirming care was associated with lower odds of depression and suicidality.
A 2024 peer-reviewed study in Nature Human Behaviour in collaboration with Trevor Project researchers found that anti-transgender state laws caused an uptick in suicide attempts among transgender youth by as much as 72%.
'Today's ruling is a devastating loss for transgender people, our families, and everyone who cares about the Constitution,' said Chase Strangio, co-director of the ACLU's LGBTQ & HIV Project who argued the case before the court, becoming the first out trans attorney to do so. 'We are as determined as ever to fight for the dignity and equality of every transgender person and we will continue to do so with defiant strength, a restless resolve, and a lasting commitment to our families, our communities, and the freedom we all deserve.'
What legal challenges could come next
Legal experts say the decision will make it difficult to battle other gender-affirming-care bans, though not impossible. 'The question presented to the Supreme Court was pretty narrow. It was very specifically this question of whether or not discrimination against trans people constitutes discrimination on the basis of sex,' says Oakley.
Cases that pertain to protected classes, such as sex and gender, are typically reviewed under the lens of heightened scrutiny. The level of scrutiny matters because it dictates the type of rationale the government must have for passing a law, says Reinert.
The majority ruled on Skrmetti with a rational review, meaning that they believed the Tennessee law did not deal with those issues but instead with matters of age and 'the medical purpose for which the treatment is being sought,' Reinert says.
'The plaintiffs argue that SB1 warrants heightened scrutiny because it relies on sex-based classifications. But neither of the above classifications turns on sex,' the majority opinion reads. 'Rather, SB1 prohibits healthcare providers from administering puberty blockers or hormones to minors for certain medical uses, regardless of a minor's sex. While SB1's prohibitions reference sex, the Court has never suggested that mere reference to sex is sufficient to trigger heightened scrutiny.'
In cases regarding the rational basis reviews of the law, 'the state almost always wins,' Reinert says.
Oakley says it's possible future plaintiffs could contest state laws based on parental rights over their child's medical treatment.
Reinert concurs that additional legal challenges can be brought in the court system depending on the way other state laws are phrased or organized. But, he adds, the decision 'almost certainly makes those challenges much harder to succeed at.'
What medical groups say about gender-affirming care
Gender-affirming care is espoused as a medically accepted treatment by every major medical association in the U.S., including the American Academy of Pediatrics, American Medical Association, and more.
The American College of Pediatricians, which has been identified as an anti-LGBTQ+ hate group by the Southern Poverty Law Center, filed an amicus brief in support of the state of Tennessee. The group was first founded in 2002 by members who opposed the American Academy of Pediatrics's endorsement of adoption by same-sex couples.
Beyond the U.S., several European countries are assessing best practices for patients with gender dysphoria. The U.K. moved to ban puberty blocker prescriptions for youth in March 2024, citing a lack of evidence.
Some doctors who treat patients with gender dysphoria have expressed disappointment with the court's ruling. 'Today's decision codifies the patchwork of state laws banning vs. allowing medically necessary healthcare for a singular group of young people into federal law,' Morissa Ladinsky, a professor at Stanford University School of Medicine and Child Health told TIME in an emailed statement. 'This emboldens a more sinister reality. Providers can now discriminate in the delivery of health care. We can treat patients differently on the basis of age, sex and gender. Because we can, does not mean we must.'