Supreme Court Upholds Ban on Transgender Care for Minors

The Supreme Court on Wednesday upheld a Tennessee law that prohibits some medical treatments for transgender youths, rejecting arguments that it violated the Constitution and shielding similar laws in more than 20 other states.

The decision, which came amid the Trump administration’s fierce assaults on transgender rights, was a bitter setback for their proponents, who only five years ago celebrated a decision by the court to protect transgender people from workplace discrimination.

The vote was 6 to 3, with the court’s three liberal members in dissent. Chief Justice John G. Roberts Jr., writing for the majority, acknowledged the “fierce scientific and policy debates about the safety, efficacy and propriety of medical treatments in an evolving field. The voices in these debates raise sincere concerns; the implications for all are profound.”

But he said these questions should be resolved by “the people, their elected representatives and the democratic process.”

The Tennessee law, enacted in 2023, prohibits medical providers from prescribing puberty-delaying medication, offering hormone therapy or performing surgery to treat gender dysphoria, the psychological distress caused by incongruence between experienced gender and that assigned at birth. It was part of a sweeping national pushback to expanding rights for transgender people. Since then, debates about military service, athletics, bathrooms and pronouns have played a role in President Trump’s second-term agenda.

In dissent, Justice Sonia Sotomayor wrote that Wednesday’s decision could have tragic consequences.

“If left untreated, gender dysphoria can lead to severe anxiety, depression, eating disorders, substance abuse, self-harm and suicidality,” she wrote in an opinion joined by Justices Elena Kagan and Ketanji Brown Jackson.

In a measure of the shifting politics around transgender issues, the Biden administration had argued against the Tennessee law. After Mr. Trump returned to office, he issued an executive order directing agencies to take steps to curtail surgeries, hormone therapy and other gender transition care for youths under 19. And in February, his administration formally reversed the government’s position in the case and urged the justices to uphold the law.

The doctor and three families who sued to challenge the Tennessee law said it discriminated based on both sex and transgender status in violation of the Constitution’s equal protection clause, which requires states to have a valid reason for treating similarly situated people differently. They noted that the law specified that the prohibited treatments were allowed when undertaken for reasons other than gender transition care.

Chase Strangio, a lawyer with the American Civil Liberties Union who had argued on behalf of the plaintiffs, said the decision was a grave disappointment. “Today’s ruling is a devastating loss for transgender people, our families and everyone who cares about the Constitution,” he said in a statement.

Jonathan Skrmetti, Tennessee’s attorney general, said the decision was a welcome victory. “In today’s historic Supreme Court win, the common sense of Tennessee voters prevailed over judicial activism,” he said in a statement.

In adopting the law, Tennessee lawmakers said the treatments had not been adequately examined in long-term medical studies and posed dangers to minors who lacked the maturity to make informed judgments.

Systematic reviews commissioned by international health bodies have consistently found that the evidence of the benefits of the treatments is weak, as is the evidence on the potential harms. Long-term risks can include the loss of fertility and the possibility that adolescents may regret their decisions down the line.

But while the published medical evidence in support of transgender care is limited, many clinicians who provide it say it can be beneficial and even lifesaving.

Hostility to transgender rights played a central role in Mr. Trump’s last presidential campaign and in the early months of his administration. At his inauguration, he announced that “it will henceforth be the official policy of the United States government that there are only two genders: male and female.”

He followed up with executive orders withdrawing federal support for transition care and banning transgender troops from military service. Democrats have struggled to respond, as polls indicate broad discomfort on transgender issues, particularly when minors are involved.

Sometimes Democrats have appeared eager to change the topic. Responding to Wednesday’s decision, Senator Chuck Schumer, the Democratic leader, said on social media that “Republicans’ cruel crusade against trans kids is all an attempt to divert attention from ripping healthcare away from millions of Americans.”

The six opinions in the decision, spanning 113 pages, were mostly devoted to whether the law should be subjected to searching judicial scrutiny to determine if it violated the Constitution. Most laws challenged on equal protection grounds must satisfy only a very relaxed standard, “rational basis scrutiny,” requiring only that legislatures have some basis for drawing distinctions. Under that standard, almost any justification for the law will do.

The Supreme Court has said that a more demanding standard, “heightened scrutiny,” is called for in assessing laws that discriminate based on sex. In such cases, states must show that the law serves an important government objective and that the discrimination is substantially related to achieving it. A key question in the case, therefore, was whether the Tennessee law in fact discriminated on the basis of sex.

Chief Justice Roberts wrote that the law drew distinctions based only on age and types of medical treatments.

Justice Sotomayor responded that the law directly took account of sex.

She added that Wednesday’s ruling was at odds with a 2020 decision, Bostock v. Clayton County, in which a majority opinion written by Justice Neil M. Gorsuch concluded that a federal civil rights law protecting workers from sex discrimination applied to transgender employees.

The plaintiffs in the case involving the Tennessee law also argued that heightened scrutiny was warranted on a second basis — because the law discriminates based on transgender status. The Supreme Court has never before recognized transgender status as a class that requires more demanding scrutiny, and Chief Justice Roberts declined to address the issue of whether it should do so now, saying instead that the law does not discriminate on that basis.

Justice Amy Coney Barrett, joined by Justice Clarence Thomas, said the court should have considered whether transgender status warrants heightened scrutiny and ruled that it does not. By failing to do so, Justice Barrett said the court had left a whole range of other laws that she indicated were plainly constitutional — including ones on bathrooms and sports — vulnerable to future litigation.

In returning the question of transition care for minors to the states, the majority echoed the court’s approach in Dobbs v. Jackson Women’s Health Organization, the 2022 decision that overturned the constitutional right to abortion. In both settings, the court ruled, elected officials rather than judges should have the last word.

The upshot will be a patchwork of laws, with both abortion and transition care largely banned in states led by Republicans but mostly permitted in ones led by Democrats.

After the Tennessee law passed, some families began making regular trips out of state to clinics that did not face similar restrictions. Others packed up and moved out of the state altogether.

People who received transition care in Tennessee before the law took effect said they counted themselves lucky but now were worried about the youths still in the state.

“Seeing kids who look like me, have the same struggle as me, not have the same hope is very hard,” said Eli Givens, who received care at 17 and testified against the bill a year later.

Azeen Ghorayshi contributed reporting from New York, and Emily Cochrane from Nashville.