Tennessee can ban gender transition care for minors, Supreme Court says

Tennessee can ban gender transition treatments for minors, a divided Supreme Court ruled Wednesday in a landmark decision on a polarizing issue the Trump administration has seized on as it targets transgender rights.

In one of the most high-profile cases of the term, the court voted 6-3 along ideological lines to uphold the state law that prohibits adolescents from using hormones and puberty blockers for gender transition.

The decision, authored by Chief Justice John G. Roberts Jr., has implications for more than 20 other states that have banned similar treatments as a growing – but still small – number of young people seek gender transition care. The ruling appears to leave opportunities for advocates to challenge other policies restricting access for transgender individuals to bathrooms, sports participation, military service and health care.

Roberts said Tennessee’s law does not discriminate on the basis of sex and that courts must give elected officials wide discretion to pass legislation when there is scientific and policy debate about the safety of medical treatments in an evolving field.

He acknowledged that “The voices in these debates raise sincere concerns; the implications for all are profound.”

Having concluded the law, which applies only to minors, does not violate the Constitution, Roberts wrote, “We leave questions regarding its policy to the people, their elected representatives, and the democratic process.”

The court’s three liberal justices dissented from the majority’s decision. Justice Sonia Sotomayor read a lengthy summary of her dissent from the bench, saying Tennessee’s law banned lifesaving medical treatment and plainly discriminates.

“By retreating from meaningful judicial review exactly where it matters most, the Court abandons transgender children and their families to political whims,” Sotomayor wrote, adding: “In sadness, I dissent.”

The ruling is only the second time the Supreme Court has addressed transgender rights. In Bostock v. Clayton County in 2020, the court said an employer who fires a worker “merely for being gay or transgender” unlawfully discriminates “because of such individual’s sex.”

The transgender teens, their parents and a doctor who sued over the Tennessee law pointed to the Bostock ruling in asserting that the treatment ban was discriminatory. But the court’s 6-3 decision Wednesday left for another day the question of whether the reasoning in Bostock applies outside of employment discrimination. The justices also have not yet grappled with looming legal questions about transgender athletes and access to bathrooms for transgender individuals.

In a statement, Tennessee Attorney General Jonathan Skrmetti praised the decision as a win for Tennessee voters and the lawmaking process.

“A bipartisan supermajority of Tennessee’s elected representatives carefully considered the evidence and voted to protect kids from irreversible decisions they cannot yet fully understand,” Skrmetti said.

ACLU attorney Chase Strangio, who represented the families behind the court challenge, called the ruling a painful setback “for transgender people, our families, and everyone who cares about the Constitution.”

“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,” said Strangio, the first openly transgender attorney to argue before the court.

Cathryn Oakley, senior director of legal policy for the Human Rights Campaign, said that while the ruling was “devastating and really scary” for families with trans children, both the question before the Supreme Court and its ruling were somewhat narrow.

“There are a lot of remaining legal pathways to challenge these laws,” Oakley said. “My heart is broken for these kids who are not going to be able to receive the medical care they need to thrive and be well, but it’s not over by any stretch.”

Soon after returning to the White House, President Donald Trump signed orders to halt transgender or nonbinary passport applications, transfer incarcerated trans women to solitary confinement and cut off young people’s access to gender transition care nationwide.

Those efforts have mostly been blocked by courts. But the justices have allowed the administration to bar transgender troops from serving in the military while litigation continues. And Trump continues to push new policies targeting LGBTQ young people. On Tuesday evening, the administration ordered The Trevor Project to shut down a suicide and crisis hotline for LGBTQ youth.

Attorney General Pam Bondi applauded the court’s decision in a post on X and encouraged other states to “follow Tennessee’s lead and enact similar legislation to protect our kids.”

The Supreme Court’s ruling in the Tennessee case will provide direction to lower courts that are also grappling with similar issues. An appeals court in Ohio in March blocked the state’s ban on treatments for young people, finding the law “unconstitutional on its face.”

The Tennessee statute adopted in 2023 prohibits young people from using hormones and puberty blockers for gender transition. Most leading medical organizations say the treatments are safe and effective. But some European countries have raised concerns.

Tennessee has characterized the treatments as unproven and risky, and the high court’s conservative majority pointed to the uncertainty in its ruling.

Hans von Spakovsky, senior legal fellow at the conservative Heritage Foundation, praised the Supreme Court for recognizing the “right of states to protect their children from hazardous medical procedures” and the Trump administration for reversing the position of the Biden administration in court.

Seven major U.S. medical associations, including the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists, called Wednesday’s ruling disappointing and said it “strips patients and families of the choice to direct their own health care.”

At issue for the justices was whether Tennessee’s law, which says the state has an interest in “encouraging minors to appreciate their sex” and in prohibiting treatments that “might encourage minors to become disdainful of their sex,” violates the equal protection clause of the Constitution.

The challengers had asked the Supreme Court to find that the law amounts to sex discrimination and should be subject to a higher standard of legal review than the lower court applied. That standard would have made it more difficult for the state to justify the ban.

The U.S. Court of Appeals for the 6th Circuit in 2023 upheld the law as constitutional, saying it bars gender transition treatments for all minors, regardless of sex. That ruling concluded that state lawmakers could have rationally determined that the law was an appropriate response to perceived risks associated with the treatments.

The Supreme Court affirmed that decision Wednesday, ruling that the law – which says no minor may be administered puberty blockers or hormones to treat gender dysphoria, gender identity disorder, or gender incongruence – treats all transgender boys and transgender girls the same way.

“The law does not prohibit conduct for one sex that it permits for the other,” wrote Roberts, who was joined in full by Justices Clarence Thomas, Neil M. Gorsuch, Brett M. Kavanaugh and Amy Coney Barrett.

The majority also said courts should not second-guess state lawmakers in an area of scientific debate. The opinion pointed to some European countries that have raised concerns about potential harms for young people using puberty blockers and hormones and studies showing insufficient data about the long-term effects. U.S. experts have disputed the characterization of some of those European findings.

“Tennessee concluded that there is an ongoing debate among medical experts regarding the risks and benefits associated with administering puberty blockers and hormones,” Roberts wrote, saying the ban “responds directly to that uncertainty.”

Justice Samuel A. Alito Jr. agreed with the majority’s judgment and wrote separately to explain his reasoning.

In dissent, Sotomayor agreed with the Biden administration and the American Civil Liberties Union that the Tennessee law discriminates based on sex because an adolescent assigned female at birth, for instance, cannot receive puberty-delaying treatments or testosterone to live as a male, but an adolescent assigned male at birth could receive such treatments.

“By depriving adolescents of hormones and puberty blockers only when such treatment is ‘inconsistent with’ a minor’s sex, the law necessarily deprives minors identified as male at birth of the same treatment it tolerates for an adolescent identified as female at birth (and vice versa),” wrote Sotomayor, joined by Justice Ketanji Brown Jackson and in part by Justice Elena Kagan.

She invoked two landmark Supreme Court decisions that eliminated discriminatory policies and said the majority was shirking its responsibility. In Loving v. Virginia, the court struck down bans on interracial marriage. In United States v. Virginia, the court ruled that the Virginia Military Institute’s male-only admissions policy was unconstitutional.

“Those laws, too, posed politically fraught and contested questions about race, sex, and biology,” Sotomayor wrote.

Sotomayor said the majority should have sent the Tennessee case back to the appeals court to determine whether a categorical ban on the treatments sufficiently protects the health of transgender teens or, instead, rests on unlawful stereotypes about how boys and girls should look and act. The justice noted that if left untreated, gender dysphoria can lead to severe depression, anxiety and self-harm.

The majority, Sotomayor wrote, “authorizes, without second thought, untold harm to transgender children and the parents and families who love them.”

Surveys have found that roughly 40 percent of transgender youths nationwide – and 93 percent of transgender youths in the South – live in states with a ban. Only a small percentage of trans minors receive medications as part of their treatment.

Though many families with trans kids have moved because of the bans, many others either can’t or do not want to relocate, said Jasmine Beach-Ferrara, executive director of Campaign for Southern Equality. Instead, they travel long distances every few months for follow-up appointments and prescription refills.

Over the past two years, Beach-Ferrara’s Asheville, North Carolina-based organization has spent $600,000 to help 1,200 families travel for medical care, sometimes up to four times a year. Though Beach-Ferrara said her organization will continue to raise money to do that work, she said Wednesday’s ruling “has compounding effects beyond the realm of health care.”

“It impacts the climate in schools,” Beach-Ferrara said. “It impacts the climate in communities, because it sends an incredibly harmful and fundamentally incorrect, untrue message about who trans young people are and what they deserve.”

West Virginia Attorney General JB McCuskey said Wednesday that he intends to use the ruling to shape his argument in other trans-related cases concerning sports and Medicaid coverage.

McCuskey said in a statement that the ruling affirms his belief that states have a “duty to protect our children” by enacting similar laws.