The U.S. Supreme Court on Wednesday upheld an appeal’s court decision that allows Tennessee to ban types of gender-affirming care for transgender minors. The ruling marks a significant blow for transgender rights advocates.

The court ruled 6-3, with the bench’s conservatives ruling in the majority.

The ACLU was among groups suing the state of Tennessee on behalf of Samantha and Brian Williams and their 15-year-old transgender daughter. They claim Tennessee’s law bans doctors from providing “medically necessary care to trans youth.” Two anonymous families are also plaintiffs in the lawsuit.

Tennessee was among 24 states that have some sort of restrictions on gender-affirming care for minors as of the time of oral arguments.

The majority opinion was authored by Chief Justice John Roberts, who addressed the science of gender-affirming care.

“This 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,” he wrote, adding that the Constitution’s Equal Protect Clause does not settle those differences.

“Questions regarding the law’s policy are thus appropriately left to the people, their elected representatives, and the democratic process,” Roberts added.

Justice Sonia Sotomayor, wrote a dissent, saying that there was no constitutional justification for the majority’s ruling.

“The majority refuses to call a spade a spade,” she said. “Instead, it obfuscates a sex classification that is plain on the face of this statute, all to avoid the mere possibility that a different court could strike down SB1, or categorical healthcare bans like it. The Court’s willingness to do so here does irrevocable damage to the Equal Protection Clause and invites legislatures to engage in discrimination by hiding blatant sex classifications in plain sight. It also authorizes, without second thought, untold harm to transgender children and the parents and families who love them.”

What is gender-affirming care?

An American Medical Association letter sent to state governors says, “Accepted medically necessary services that affirm gender or treat gender dysphoria may include mental health counseling, non-medical social transition, gender-affirming hormone therapy, and/or gender-affirming surgeries.”

RELATED STORY | Supreme Court will take up state bans on gender-affirming care for minors

In a 2020 amicus brief filed in a federal court case by various medical organizations, it says surgery is “appropriate and medically necessary” for some patients.

“These procedures could include chest reconstruction surgery for transgender men, breast augmentation for transgender women, or genital surgeries, including removal of the testicles, the primary source of testosterone production, in women who are transgender,” the brief said.

The Supreme Court on Wednesday ruled that Tennessee’s ban on gender-affirming care for transgender youth should remain in place. The court found that Tennessee’s law restricting certain medical treatments for trans minors does not violate the 14th Amendment’s equal protection clause — a finding that experts worry will set new precedent for how transgender people can be treated under the U.S. Constitution.

This 6-3 opinion, signed by Chief Justice John G. Roberts Jr., will further restrict a form of health care that has been increasingly banned for transgender youth across the country, both by Republican state lawmakers and by the Trump administration. Twenty-five states ban hormone replacement therapy and puberty blockers for trans youth, as well as surgeries, which are rare for minors; two other states ban only surgeries. Of those 25 states, six have made it a felony for medical providers to administer gender-affirming care, according to the Movement Advancement Project, which tracks LGBTQ+ policy.

Roberts wrote that “the voices in these debates raise sincere concerns; the implications for all are profound.” He emphasized, however, that the court’s role is to ensure that the law does not violate the equal protection clause. “Having concluded that it does not,” he added, “we leave questions regarding its policy to the people, their elected representatives, and the democratic process.”

The Supreme Court’s ruling was narrower than it could have been, attorneys with the ACLU and Lambda Legal said in a call with reporters on Wednesday. This narrow scope precludes some of the broader consequences that could have come from Wednesday’s ruling and provides them with other avenues to challenge anti-trans laws, they said.

The court did not address whether Bostock v. Clayton County, the Supreme Court case that found LGBTQ+ people are protected against workplace discrimination, reaches beyond Title VII into areas like health care. The court also did not weigh on whether trans people broadly constitute a suspect class — meaning, if they have been historically subject to discrimination and therefore receive extra protections against discrimination under the Constitution. The justices were also clear that their decision only applies to gender-affirming care for minors.

Although this case impacts specifically Tennessee, the Supreme Court has now signaled that it does not plan to intervene when other states restrict medical care for trans youth. This may embolden more states to ban the care and it could also complicate ongoing lawsuits against current state bans. At least 110,000 transgender youth already live in states that restrict or limit gender-affirming care access, according to the Williams Institute at UCLA School of Law. Many families of trans kids have left these states to find health care elsewhere — and so have the doctors providing it.

Hormone replacement therapy (HRT) is used by many trans people to treat gender dysphoria, which is a strong and persistent distress felt when one’s body is out of sync with their identity. Without treatment, gender dysphoria can severely and negatively impact day-to-day life. HRT is also used to treat menopause and conditions like polycystic ovary syndrome. However, its use specifically to treat gender dysphoria in trans people, and particularly trans youth, is what has come under intense political scrutiny in the past five years.

Justice Sonia Sotomayor, one of three justices to vote against upholding Tennessee’s ban, wrote: “[The Court] authorizes, without second thought, untold harm to transgender children and the parents and families who love them. Because there is no constitutional justification for that result, I dissent.”

Opponents of gender-affirming care say that teenagers starting hormone replacement therapy — and pre-pubescent children taking puberty blockers — are too young to make these medical decisions. However, opponents often inaccurately portray the care as rushed, sloppy or even akin to mutilation. To obtain gender-affirming care, a young trans person works with their parents and doctors over the course of months or years to prove that medical intervention is right for them. Medical providers stress that there is not a “one-size-fits-all” approach and that side effects, like the risk of decreased bone density when taking puberty blockers, are closely monitored and communicated to patients.

In Tennessee, many families of transgender youth are discussing moving out of the state or out of the country, based on the state’s gender-affirming care ban as well as President Trump’s executive orders targeting transgender people, said Lucas Cameron-Vaughn, a senior staff attorney with ACLU of Tennessee. Other families have been traveling out of state to obtain gender-affirming care for their children, he said, which means taking time off of work, taking kids out of school, and spending money that they may or may not have.

The ruling comes in the middle of Pride month, an annual celebration of LGBTQ+ life and history. Past blockbuster LGBTQ+ rights decisions have historically fallen in mid to late June, but those have largely extended civil rights protections. Lawrence v. Texas, which struck down sodomy laws, was released June 26, 2003. The Windsor decision, which repealed the federal ban on marriage equality, was decided June 27, 2013, and the Obergefell ruling that granted same-sex couples the right to marry two years later came out June 26. The Bostock decision, which found that sex protections for women applied to LGBTQ+ people in the workplace, was released June 15, 2020.

But two years ago, on June 30, the court ruled that the state of Colorado could not force a website designer to serve LGBTQ+ couples seeking wedding websites. And again on Wednesday, the court veered from extending rights to LGBTQ+ people during Pride month to taking them away.

Major medical groups including the American Medical Association, American Psychological Association and the American Academy of Pediatrics have endorsed the use of gender-affirming care for transgender youth. The new president of the World Professional Association for Transgender Health, which sets global standards for doctors and nurses providing health care to trans patients, has expressed concerns that banning gender-affirming care will simply drive the care underground and endanger patients.

The decision on Wednesday upholds the 6th U.S. Circuit Court of Appeals’ conclusion in 2023, which allowed Tenneesse’s ban to take hold over a statewide injunction. This case began in April 2023 as L.W. v. Skrmetti, when the ACLU and Lambda Legal sued Tennessee — via the state’s attorney general, Jonathan Skrmetti — to block the state’s health care ban. Attorneys filed the lawsuit on behalf of Samantha and Brian Williams of Nashville and their teenage daughter, two other families of trans youth and Dr. Susan Lacy, a Memphis-based gynecologist providing gender-affirming care to adults and minors.

WASHINGTON − An ideologically divided Supreme Court upheld Tennessee’s ban on gender-affirming care for minors, a major setback for transgender Americans who have increasingly become targets of conservative states and the Trump administration.

The court’s six conservative justices upheld the ban, and the three liberals dissented.

The June 18 decision − one of the court’s biggest this year − came about five years after the court ruled that transgender people, as well as gay and lesbian people, are protected by a landmark civil rights law barring sex discrimination in the workplace.

But in this case, the court said preventing minors from using puberty blockers and hormone therapy does not violate the equal protection clause of the 14th Amendment, which requires the government to treat similarly situated people the same.

“Having concluded it does not, we leave questions regarding its policy to the people, their elected representatives, and the democratic process,” Chief Justice John Roberts wrote for the majority.

In her dissent, Justice Sonia Sotomayor said the court retreated “from meaningful judicial review exactly where it matters most,” and “abandons transgender children and their families to political whims.”

Sotomayor read part of her lengthy dissent from the bench, a rare step typically done to stress disapproval.

Tennessee praises ‘landmark victory’

Tennessee Attorney General Jonathan Skrmetti called the decision a “landmark victory … in defense of America’s children.”

“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,” he said in a statement about the 2023 law.

The court’s ruling that Tennessee’s law is subject to the lowest level of judicial scrutiny means similar laws in other states are more likely to be upheld.

ACLU lawyer: `Painful setback’

Chase Strangio, a lawyer with the American Civil Liberties Union who represented the Tennessee families challenging the law, said the decision is a “painful setback.”

But Strangio, the first openly transgender person to argue before the court, said the opinion left ways to fight other restrictions on medical care as well as various actions against transgender people taken by the Trump administration.

“This is a setback in many ways but we continue on with the fight,” he said.

Dispute over discrimination

The Biden administration and the Tennessee families that challenged the law argued it discriminated against transgender people because a teenager whose sex assigned at birth is male may be given testosterone to treat delayed puberty, but a teenager assigned female at birth who wants testosterone to treat gender dysphoria may not have it.

Tennessee countered that the treatments have different risks and benefits when used by transgender young people, who need to be protected from life-altering consequences.

The Supreme Court agreed, saying the law is removing one set of diagnoses − gender dysphoria − from the range of treatable conditions, not excluding people from treatment because they’re transgender.

Trump administration sided with Tennessee

After the case was argued in December, the Justice Department under President Donald Trump told the court it was no longer against Tennessee’s law.

Trump made opposition to transgender rights a central theme of his presidential campaign.

The issue, a major flashpoint in the culture wars, gained prominence with startling speed, despite the tiny – though increasing – fraction of Americans who are transgender.

Since 2022, the number of states taking steps to limit access to gender-affirming care for minors grew from four to about half.

States have also taken steps to restrict the bathrooms transgender students can use, what sports teams they can join. and whether they can change the sex designation on their birth certificates.

Path to the Supreme Court

When families with transgender children challenged bans on gender-affirming care, district courts largely sided with them and blocked enforcement. But three appeals courts upheld the laws, including the Cincinnati-based 6th U.S. Circuit Court of Appeals.

Tennessee’s law was the first to reach the Supreme Court.

During oral arguments in December, several of the conservative justices voiced support for taking a similar approach to what the court did when it overturned Roe v. Wade, finding there’s no constitutional barrier to the question at hand and leaving it up to state and federal legislatures to decide.

“My understanding is the Constitution leaves that question to the people’s representatives, rather than to nine people, none of whom is a doctor,” Chief Justice John Roberts said in December’s debate.

Liberal justices say law discriminates

The court’s liberal justices had argued that the court can’t ignore constitutional protections, particularly for the vulnerable.

“That’s a question for the court,” Justice Ketanji Brown Jackson said.

Sotomayor wrote in her dissent that the law “plainly discriminates on the basis of sex,” tying it to the 2020 decision barring employment discrimination for transgender people.

Roberts responded that the court didn’t decide in 2020 whether the reasoning could be applied outside of the civil rights law at issue in that case. And the court didn’t need to now, he said, because neither a teen’s sex nor transgender status is the reason the minor can’t get puberty blockers under Tennessee’s law.

What medical experts say

Gender-affirming care for minors is supported by every major medical organization, including the American Medical Association, the American Academy of Pediatrics and the American Psychiatric Association.

But the court’s conservative justices focused more on the fact that some European countries have tightened restrictions on the treatments. England’s National Health Service, for example, stopped prescribing the drugs outside of clinical trials after a review concluded more data was needed to help doctors and their patients make informed decisions.

Tennessee, Roberts wrote, concluded that there’s an ongoing debate among medical experts about the risks and benefits of the treatments.

“Recent developments,” he said, “only underscore the need for legislative flexibility in this area.”

The case is U.S. v. Skrmetti.

By John Kruzel

WASHINGTON (Reuters) -The U.S. Supreme Court sided on Thursday with a severely epileptic girl who is pursuing a disability discrimination lawsuit against a Minnesota public school district in a ruling that bolsters protections for students with disabilities in American schools.

The 9-0 ruling threw out a lower court’s decision that the Osseo Area Schools district had not discriminated against student Ava Tharpe in violation of two federal disability rights laws, as a lawsuit brought by her parents argued.

Chief Justice John Roberts, who authored the ruling, wrote that the St. Louis-based 8th U.S. Circuit Court of Appeals erred by requiring students to satisfy a heightened legal standard for disability discrimination claims against schools than is typically required in other contexts.

Federal appeals courts had been divided on whether disability discrimination claims arising in school settings require a heightened legal standard, meaning the stricter requirement had applied in some parts of the country but not others. The Supreme Court ruling harmonizes the standard nationally.

Claims brought under the Americans with Disabilities Act of 1990 and the Rehabilitation Act of 1973 that are “based on educational services should be subject to the same standards that apply in other disability discrimination contexts,” Roberts wrote.

Roberts added that nothing in the relevant text of those laws suggests that “such claims should be subject to a distinct, more demanding analysis.”

Roman Martinez, a lawyer for Tharpe, called the ruling “a great win for Ava, and for children with disabilities facing discrimination in schools across the country.”

“We are grateful to the Supreme Court for its decision holding that these children should enjoy the same rights and protections as all other Americans with disabilities,” Martinez said, adding that ruling would “protect the reasonable accommodations needed to ensure equal opportunity for all.”

Tharpe suffers from severe epilepsy that prevents her from attending school before noon due to morning seizures but permits her to engage in school work after that until about 6 p.m.

At issue in the case was whether the legal standard applied by the 8th Circuit in rejecting Tharpe’s discrimination claims was overly strict, and if a less stringent standard should have applied.

When Tharpe and her family lived in Kentucky, her public school district tailored an education plan to her disability that included supplemental evening instruction at home, providing her with the same amount of school time as her peers.

In 2015, her family moved to Minnesota, and Tharpe began attending the public schools in the Osseo Area Schools district in the suburbs of Minneapolis. For years, the district refused to accommodate a request by her parents that she receive evening instruction, leading Tharpe to receive fewer hours of education per day compared to her peers, according to court papers.

Tharpe and her parents in 2021 filed a federal lawsuit accusing the Osseo district of discrimination under two federal disability laws. The lawsuit sought an accommodation from the district giving the girl the equivalent of a full school day, as well as monetary damages.

U.S. District Judge Michael Davis in Minneapolis in 2023 ordered the school district to extend Tharpe’s instructional day until 6 p.m. and to provide compensatory hours of instruction. But the judge rejected Tharpe’s discrimination claims, ruling that her parents had failed to show that the school district satisfied a heightened legal standard of “bad faith or gross misjudgment.”

The 8th Circuit upheld the judge’s ruling, prompting Tharpe and her parents to appeal her disability discrimination claims to the Supreme Court.

(Reporting by John Kruzel; Editing by Will Dunham)

The Williams family sued in 2023 after access to gender-affirming care for transgender teenagers was banned in Tennessee.

The U.S. government initially argued against Tennessee’s law, before flipping positions after President Donald Trump took office.

The ruling will likely set broad precedent on how constitutional protections apply to transgender people.

The U.S. Supreme Court in a 6-3 decision upheld Tennessee’s ban on gender transition treatments for transgender minors in a case brought by a Nashville family.

The ruling comes six months after the high court heard arguments in the case that will likely have broad ripple effects for transgender youth across the nation, not just for the family who initially challenged the state in 2023.

Chief Justice John Roberts, writing the majority opinion, found that Tennessee’s law barring transgender minors from using treatments like puberty blockers and hormone therapy does not violate the Equal Protection Clause of the Constitution, which requires that the government treat similarly situated people the same.

“This 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,” Roberts wrote. “The voices in these debates raise sincere concerns; the implications for all are profound. The Equal Protection Clause does not resolve these disagreements. Nor does it afford us license to decide them as we see best.”

Roberts wrote, “we leave questions regarding (the law’s) policy to the people, their elected representatives, and the democratic process.” The ruling will likely keep in effect laws similar to Tennessee’s that have been enacted in 26 other states, according to the Liberty Counsel, an evangelical Christian legal group.

Reactions to the ruling

Tennessee Attorney General Jonathan Skrmetti’s office defended the law in court. He said in a statement “the common sense of Tennessee voters prevailed over judicial activism.”

“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,” he said. “I commend the Tennessee legislature and Governor Lee for their courage in passing this legislation and supporting our litigation despite withering opposition from the Biden administration, LGBT special interest groups, social justice activists, the American Medical Association, the American Bar Association, and even Hollywood.”

Gov. Bill Lee, in a statement, thanked Skrmetti for securing the “historic ruling” and said the legislation is intended to protect young people.

“Protecting children is a fundamental responsibility that we take seriously, and I was proud to sign this bipartisan legislation that lawfully safeguards young people from irreversible, life-altering medical decisions,” Lee’s statement reads. “Voters, through their elected representatives, should have the power to decide what they believe on serious issues like this one.”

Tennessee Senate Minority Leader Raumesh Akbari, D-Memphis, called the ruling a harmful setback for “anyone who believes in the basic freedom to make personal medical decisions without government interference.”

““Tennessee’s law was always about politics, not protecting children,” Akbari said. “It strips away the rights of loving families and qualified professionals to make decisions based on science and compassion. Now, the highest court in the land has greenlit that overreach, opening the door for even more intrusion into private healthcare choices.”

Justices Sonia Sotomayor, Elena Kagan and Ketanji Brown Jackson dissented. Sotomayor wrote that the court’s decision does “irrevocable damage to the Equal Protection Clause and invites legislatures to engage in discrimination by hiding blatant sex classifications in plain sight.”

“It also authorizes, without second thought, untold harm to transgender children and the parents and families who love them,” she wrote. “Because there is no constitutional justification for that result, I dissent.”

Advocacy groups were disappointed in the ruling.

The Tennessee Equality Project, a statewide nonprofit advocating for LGBTQ+ rights, said in a statement, “equal access to health care and bodily autonomy are fundamental human rights for every person, including our transgender children and youth.” The American Academy of Pediatrics, the largest professional association of pediatricians in the U.S., supports the use of gender-affirming medical care, the Tennessee Equality Project said.

“The consequences of this devastating decision will be felt by anyone who needs gender-affirming care; worse for transgender patients already facing widespread discrimination in hostile states,” the group’s statement reads.

While the ruling allows states to bar access to gender-affirming treatment for minors, the court left other protections for transgender people in place, the American Civil Liberties Union noted in its statement.

“Though this is a painful setback, it does not mean that transgender people and our allies are left with no options to defend our freedom, our health care, or our lives,” Chase Strangio, co-director of the ACLU’s LGBTQ and HIV Project. “The Court left undisturbed Supreme Court and lower court precedent that other examples of discrimination against transgender people are unlawful.”

Family filed suit over Tennessee law

Samantha and Brian Williams, along with their teenage daughter identified in court documents as L, sued after Republicans lawmakers banned medications like puberty blockers and hormone therapy to treat gender dysphoria.

The ban blocked L from receiving prescriptions, but other Tennessee teens can be prescribed the same medications, as long as they’re not transgender.

“Puberty has a lot of irreversible damage that comes with it,” L told The Tennessean in 2024. “So, I think to say that you should wait to make the decision until you’re 18 has a lot of consequences and permanent aspects to it.”

The 2023 law also banned gender transition surgeries for minors, which were rare in the state. The surgical ban was not debated in the Supreme Court case.

The Supreme Court in the past upheld the legality of a California insurance program that excluded from coverage certain health issues that result from pregnancy. Rather than discriminating based on sex, the program discriminated based on pregnancy status, and non-pregnant people include both men and women, the court decided in that case.

“By the same token, SB1 does not exclude any individual from medical treatments on the basis of transgender status,” the majority wrote. “Rather, it removes one set of diagnoses — gender dysphoria, gender identity disorder, and gender incongruence — from the range of treatable conditions.”

Because the law does not distinguish between people based on sex or transgender status, the law is not subject to a stricter legal standard called heightened scrutiny, the court said.

The new Tennessee law threw L’s treatment into disarray, as her parents raced to find medical care in other states as similar laws began falling across the country. L eventually established medical treatment in North Carolina and was grandfathered in before the state passed its own ban.

The Williams family was initially successful in challenging Tennessee’s ban.

A Nashville-based federal court sided with the Williams family and other plaintiffs, finding the state likely did not craft its law without infringing on constitutional rights, while the state said Republican lawmakers passed the law to protect kids from serious medical risk. The 6th Circuit Court of Appeals sided with the state and overturned an injunction blocking the law.

Case expected to set precedent

The case is expected to set a precedent for how constitutional protections against sex discrimination — the 14th Amendment’s Equal Protection clause — can be applied for transgender people. The ruling does not, however, mean gender-affirming care is banned nationwide.

The ruling also does not necessarily mean all bans on gender-affirming care for minors cannot be challenged legally, according to Karen Loewy, director of constitutional law practice at Lambda Legal, a civil rights organization for LGBTQ+ people.

“There is nothing in this opinion that is a mandate,” Loewy said in a virtual news conference after the decision was released. “There’s nothing in this opinion that is a green light for others to join the bandwagon here of discriminating against trans young people.”

In the Supreme Court arguments, attorneys for the plaintiffs and the U.S. Department of Justice argued Tennessee’s ban ran afoul of constitutional protections. The federal government later flipped its position on the case, however, after President Donald Trump took office in January.