Supreme Court to confront dispute over gender-affirming care for transgender minors

Washington — The Supreme Court is set to convene Wednesday to hear arguments in a landmark case involving access to gender-affirming care like puberty blockers and hormone therapy for minors experiencing gender dysphoria.

The case concerns the constitutionality of a Tennessee law that bans this medical care for transgender adolescents. Half the states have measures on the books that are similar to Tennessee’s, and advocates for transgender rights are warning that if the Supreme Court upholds the ban, it would open the door to state lawmakers outlawing gender-affirming care for adults.

The dispute is the first in which the justices will consider the constitutionality of state efforts to regulate medical interventions for transgender youth, but it comes as Republican-led states have enacted a slew of restrictions targeting transgender individuals, including policies on sports teams and restroom access.

President-elect Donald Trump has vowed to restrict medical treatments for transgender minors and bar transgender athletes from participating in women’s sports. And while the Biden administration will argue Wednesday that the Supreme Court should invalidate Tennessee’s law, the incoming Trump administration could reverse the government’s position once it is in power early next year.

That shift in stance, though, may not preclude the high court from issuing a decision in the case, expected by the end of June.

“It’s very difficult for these teenagers, who already face a difficult scenario, when there’s this institutional governmental rejection of who they are,” said Dr. Susan Lacy, a Memphis-based physician who challenged Tennessee’s law alongside three families. “That’s very difficult to be told either you don’t know who you are — being told that you’re wrong, you don’t know what you’re talking about, your parents are trying to manipulate you, all of that kind of rhetoric is really difficult for these kids.”

Tennessee’s ban on gender-affirming care

Known as SB1, Tennessee’s Republican-led legislature approved its ban on certain medical treatments for minors experiencing gender dysphoria in March 2023. Puberty blockers and hormone therapy have been used to treat gender dysphoria for decades, but in the past three years, GOP-controlled state legislatures have adopted measures restricting access to these treatments for minors.

Tennessee’s law prohibits health care providers from administering any puberty blocker or hormone if they’re meant to enable “a minor to identity with, or live as, a purported identity inconsistent with the minor’s sex.” The state argues that it has a “compelling interest in encouraging minors to appreciate their sex, particularly as they undergo puberty,” and in barring procedures that “might encourage minors to become disdainful of their sex.”

The use of these treatments for conditions such as precocious puberty, congenital defects or other diseases is allowed in Tennessee.

The Biden administration argues that Tennessee’s ban draws lines based on sex and discriminates against transgender people, in violation of the Constitution’s guarantee of equal protection. The Justice Department has argued that the law should be subject to a more stringent level of judicial review, known as heightened scrutiny, rather than the more relaxed standard applied by the lower court, rational basis review.

“Most immediately, SB1 prohibits transgender adolescents, their parents, and their doctors from making critically important and intensely personal decisions about the appropriate medical treatment for what everyone agrees is a serious medical condition,” Solicitor General Elizabeth Prelogar, who will argue on behalf of the federal government, wrote in a filing with the high court.

But Tennessee officials assert that the law is a routine exercise of state power to regulate medicine, and it is medical use and purpose — not sex — that dictate the availability of treatments. The state, they have said, is trying to protect children from the “life-altering risks” of gender-affirming care, which they said is “risky” and “unproven.”

“While the government is free to favor its transition-first, ask-questions-later approach, the Constitution does not bind Tennessee to that same choice,” state officials wrote in a filing with the Supreme Court.

The challenge before the high court was brought by three families and Lacy, who began providing gender-affirming care eight years ago. One of the challengers, a transgender girl identified in court filings as L.W., was diagnosed with gender dysphoria at the age of 12 and began taking puberty blockers, followed by hormones.

Today, the state’s ban means L.W., now 16, must travel to another state to receive her treatments.

“Tennessee’s ban on gender-affirming medical care is an active threat to the future my daughter deserves,” Brian Williams, L.W.’s father, told reporters in a press call hosted by the ACLU. “It infringes not only on her freedom to be herself, but on our family’s love for her.”

The ACLU is representing the families who challenged Tennessee’s law. Chase Strangio, a lawyer with the group, will make history as the first openly transgender person to argue before the Supreme Court when he participates in oral arguments Wednesday.

A federal district court ruled for the Biden administration and the challengers, finding that Tennessee’s ban likely violates the Constitution’s Equal Protection Clause. The court ruled the law discriminates based on sex and targets transgender people, and said the benefits of the health care outlawed by the law are “well-established.”

But the U.S. Court of Appeals for the 6th Circuit reversed the lower court’s decision and allowed Tennessee’s law to take effect. The measure, the divided panel found, regulates gender-affirming care for all minors, regardless of sex.

“Life-tenured federal judges should be wary of removing a vexing and novel topic of medical debate from the ebbs and flows of democracy by construing a largely unamendable Constitution to occupy the field,” Chief Judge Jeffrey Sutton wrote.

The Biden administration and the families appealed the 6th Circuit’s decision to the Supreme Court, which agreed in June to review the ruling.

A “sense of mental clarity”

The Williams Institute, a think tank that conducts research on sexual orientation and gender identity law, estimates there are roughly 1.6 million people ages 13 and older who identify as transgender. There are more than 300,000 transgender youth between the ages of 13 and 17 who live in states where access to puberty blockers and hormones is restricted, according to the center.

Daniel Trujillo, a 17-year-old transgender boy who lives in Tucson, Arizona, began social transitioning when he was 8 years old and was prescribed puberty blockers after years of discussions between his parents, pediatrician and, later, a clinical psychologist.

“I myself am proof that gender-affirming care works and it helps people and it saves lives,” he told CBS News. “When I was experiencing a lot of dysphoria, it was really hard for me to focus on things that mattered. I couldn’t focus on school. I was very anxious and internalizing whatever I was experiencing, and once I was able to feel more comfortable in myself and feel affirmed with me, as who I am, my parents were able to see the shift, my friends and family could see the shift.”

In 2022, then-Gov. Doug Ducey, a Republican, signed into law a bill that prohibits “irreversible gender reassignment surgery” for minors. An earlier version of the proposal would have also outlawed puberty blockers and hormone therapy, but it failed in a state senate committee.

Still, Lizette Trujillo, Daniel’s mother, said that had the state banned those treatments, the family would have moved elsewhere to ensure her son could continue to receive medical care. 

“That felt really scary, because here is my child who is emotionally well, who has maintained strong self-esteem, feels love, he’s doing well. And then to have the state infringe on our right and totally change our trajectory or change his life felt awful, it felt scary and felt unjust,” she told CBS News.

Medical interventions in minors experiencing gender dysphoria began in Europe in the late 1990s, when Dutch health care providers started offering puberty blockers. In 1998, the World Professional Association for Transgender Health recommended puberty blockers at the start of puberty and hormone treatment for transgender youth at 16.

In recent years, though, some health authorities in European nations have warned of insufficient evidence on the efficacy of treatments for transgender youth.

Sonia Suter, a law professor at George Washington University Law School, said the Supreme Court could side with Tennessee and conclude that it should give deference to the state legislature in regulating health care because of medical uncertainty and disagreement among experts.

Citing an independent review from the United Kingdom, after which England’s National Health Service stopped prescribing puberty blockers and hormones to minors with gender dysphoria, Suter that it could “make it easy for the U.S. Supreme Court to say, you know what, there is clearly medical uncertainty here and therefore we’re not going to second-guess.”

In filings with the Supreme Court, Tennessee officials warn that treatments for gender dysphoria carry health risks, such as negative impacts to fertility, diminished bone density and a higher risk of cancer.

But Lacy, the provider who has roughly 700 transgender patients out of roughly 3,000 who visit her practice, said she has not seen any major complications affecting long-term health.

“When I first started providing trans care, the most compelling piece of it was that, prior to any sort of physical changes or obvious transitional changes, the first thing that people would tell me is that they felt like there was sort of a sense of mental clarity that they experienced,” she said.

If not treated, gender dysphoria can lead to physical and psychological harms, the Biden administration has warned, including depression and self-harm. Up to one-third of transgender high school students attempt suicide in a given year, according to a study from the Centers for Disease Control and Prevention.

“It’s this goose chase trying to find safety, which is not the American dream that everyone talks about,” Daniel Trujillo said of the patchwork of state laws restricting gender-affirming care. “All American citizens should be able to live freely wherever they want to and live fully wherever they want to.”

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