The Supreme Court upheld Tennessee’s law banning gender-affirming healthcare for transgender minors, delivering a major blow to access to care for trans people as the Trump administration seeks to end federal recognition of trans people entirely.
The high court’s 6-3 decision on Wednesday written by Chief Justice John Roberts is expected to have nationwide impacts, after more than two dozen states enacted similar bans on access to hormone therapy and other gender-affirming healthcare for trans people under 18.
All three liberal justices dissented. “The court abandons transgender children and their families to political whims,” Justice Sonia Sotomayor wrote in her dissenting opinion, which she read from the bench in a rare rebuke of the court’s conservative majority.
Justices were asked to decide whether states that ban transgender children from medically recommended healthcare qualifies as unconstitutional sex discrimination under the 14th Amendment’s equal protection clause.
“This case presents an easy question,” she said. “Because sex determines access to the covered medications, it clearly does. Yet the majority refuses to call a spade a spade.”
The court’s “willingness” to strike down Tennessee’s law does “irrevocable damage to the Equal Protection Clause and invites legislatures to engage in discrimination by hiding blatant sex classifications in plain sight,” Sotomayor wrote.
The conservative majority’s ruling “also authorizes, without second thought, untold harm to transgender children and the parents and families who love them,” she added.
Writing for the majority, Roberts said the 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.”
“The voices in these debates raise sincere concerns; the implications for all are profound,” he wrote. “The Equal Protection Clause does not resolve these disagreements. Nor does it afford us license to decide them as we see best.”
The court leaves questions surrounding policy targeting trans youth to “the people, their elected representatives, and the democratic process,” he added.
During December’s oral arguments in United States v Skrmetti, several conservative justices suggested they would leave a decision on standards for trans healthcare up to individual states, echoing similar arguments from the landmark ruling that revoked a constitutional right to abortion care.
The justices heard more than two hours of wide-ranging arguments and questions on whether trans people can be constitutionally protected from discrimination.
Justice Samuel Alito grilled ACLU attorney Chase Strangio, the first-ever openly trans attorney to present at the high court, to repeatedly cast doubt on whether being transgender is an “immutable” characteristic and thus protected by anti-discrimination laws.
“I think that the record shows that the discordance between a person’s birth, sex and gender identity has a strong biological basis and would satisfy an immutability test,” Strangio replied.
Wednesday’s ruling is “a devastating loss for transgender people, our families, and everyone who cares about the Constitution,” Strangio said in a statement following the ruling.
Crucially, the ruling does not extend to other court precedent surrounding discrimination against trans people, yet it “creates a class of people who politicians believe deserve healthcare, and a class of people who do not,” according to Lucas Cameron-Vaughn, senior staff attorney at the ACLU of Tennessee.
Tennessee families with trans children are considering moving out of the state — or the country — to continue their care regimen over mounting costs for travel to states where care is protected, Vaughn told reporters on Wednesday.
In 2020, medically necessary gender-affirming healthcare was available to transgender young people in every state. Within the years that followed, that same healthcare was outlawed in nearly half of states, after hundreds of bills targeting LGBT+ young people flooded statehouses on a wave of anti-trans rhetoric that dominated campaign messaging into the 2024 presidential election.
South Dakota was the first state to introduce an outright ban. Arkansas was the first to make one law. By the end of 2024, 26 states made affirming care for trans minors illegal. Nearly 40 percent of trans youth aged 13 to 17 — roughly 119,000 children — are living in those states, according to the Human Rights Campaign.
One week after his inauguration, Trump signed an executive order directing federal agencies to rescind policies that support or acknowledge gender-affirming healthcare for transgender Americans.
He also issued an executive order effectively ending federal recognition of trans people across the government, forming the basis for several other orders focused exclusively on trans people, their healthcare and whether they can serve in the U.S. military.
The president’s sweeping order on gender-affirming care targets the prescription of puberty blockers, hormone therapies and affirming surgeries for anyone under 19 years old — an age group that includes adult Americans.
Major medical organizations including the American Academy of Pediatrics, the American Medical Association, American Academy of Child and Adolescent Psychiatry and American Counseling Association, among others, agree that such care is clinically appropriate for trans youth experiencing gender dysphoria. Medical guidelines generally say that affirming surgeries should only be approved for people ages 18 and older, and they are rarely, if ever, performed.
“It’s jaw-dropping to see a majority of Supreme Court justices turn a blind eye while transgender minors are flatly denied access to health services in consultation with their doctors,” according to Lawrence Gostin, co-faculty director with the O’Neill Institute for National and Global Health Law.
“Discrimination has no place in America, and it is sad to see the nation’s highest court side with states that discriminate against our most vulnerable and marginalized citizens,” he added.
The Supreme Court “failed to do its job,” according to Jennifer Levi, senior director of transgender and queer rights with GLAD Law.
“When the political system breaks down and legislatures bow to popular hostility, the judiciary must be the Constitution's backbone,” she added. “Instead, it chose to look away, abandoning both vulnerable children and the parents who love them. No parent should be forced to watch their child suffer while proven medical care sits beyond their reach because of politics.”
