Dive Brief:
The Supreme Court on Wednesday issued a highly anticipated ruling upholding a Tennessee law banning gender-affirming care for minors. The court voted 6 to 3, with the court’s three liberal justices dissenting.
Tennessee’s law, SB1, prohibits providers from offering transgender patients under the age of 18 medical treatments like puberty blockers or hormone therapy for gender dysphoria.
In the majority opinion, Chief Justice John Roberts said the ruling returned the question of youth gender-affirming care to “the people, their elected representatives, and the democratic process.”
Dive Insight:
United States v. Skrmetti was filed last year by families of transgender children and a provider in Tennessee, who argued that the state’s law violated the equal protection clause of the 14th Amendment and discriminated based on sex.
The law prohibited minors from seeking gender-affirming care to receive medications, including puberty blockers and hormone therapies, to treat gender dysphoria — a condition that causes patients to feel their biological sex does not match their gender expression.
Tennessee argued that the ban protected children from unproven medical treatments — a position that has been echoed by the Trump administration this year, even though most medical organizations in the U.S. and medical researchers endorse the treatments.
Justices Clarence Thomas, Samuel Alito, John Roberts, Neil Gorsuch, Brett Kavanaugh and Amy Coney Barrett sided with the state, ruling the law does not bar patients from treatment based on sex, but on age and medical condition. Under that framework, the law needed to meet a lower legal threshold to be deemed constitutional, according to the justices.
“SB1 prohibits healthcare providers from administering puberty blockers or hormones to any minor to treat gender dysphoria, gender identity disorder, or gender incongruence, regardless of the minor’s sex; it permits providers to administer puberty blockers and hormones to minors of any sex for other purposes,” Roberts wrote.
The majority also expressed skepticism about the validity of gender-affirming care for minors, calling it an evolving field. Roberts said the evidence supporting the use of puberty blockers and hormone therapies was “remarkably weak” in the majority opinion.
In the dissenting opinion, Justice Sonia Sotomayor said the majority’s logic did not stand up to scrutiny.
Under Tennessee’s ban, two patients seeking treatment for unwanted facial hair, for example, would be treated or turned away depending entirely on their sex. SB1 allows a minor girl to receive puberty blockers for the symptoms, because facial hair does not align with her sex, while a male patient who wished to suppress the same trait would not qualify for care, she wrote.
“The problem with the majority’s argument is that the very ‘medical purpose’ SB1 prohibits is defined by reference to the patient’s sex,” Sotomayor wrote. “Key to whether a minor may receive puberty blockers or hormones is whether the treatment facilitates the ‘medical purpose’ of helping the minor live or appear ‘inconsistent with’ the minor’s sex. That is why changing a patient’s sex yields different outcomes under SB1.”
Liberal Justices Elena Kagan and Ketanji Brown Jackson joined Sotomayor in dissenting.
The decision comes amid a growing debate about how to care for transgender minors. Since 2021, 26 states have passed bans on gender-affirming care for children, according to a tracker maintained by the Human Rights Campaign.
Even in states without bans, pressure has increased on providers to offer conversational therapy instead of medications. Last month, the CMS demanded hospitals that offer gender-affirming care for children turn over financial information and clinical protocols related to the services. In the same week, the HHS implored hospitals to update protocols to more heavily utilize the Trump administration’s preferred treatment of talk therapy.
Losing access to gender-affirming care treatments can have health impacts for patients, patient advocates have warned. In a dissenting opinion, Sotomayor cited evidence finding the lifetime prevalence of suicide attempts for transgender individuals can be as high as 40%.
“By retreating from meaningful judicial review exactly where it matters most, the Court abandons transgender children and their families to political whims,” Sotomayor said.
