A Single Supreme Court Ruling Could Shape The Future Of Transgender Health Care

The U.S. Supreme Court on Wednesday will hear arguments for the most important transgender rights case it has ever reviewed — one that could have significant consequences on the future of lifesaving gender-affirming care for youth in the country.

At the heart of the case, United States v. Skrmetti, is the question of whether a Tennessee ban on such care violates the 14th Amendment’s equal protection clause, which bars discrimination on the basis of sex. The Tennessee law, Senate Bill 1, encourages minors to “appreciate their sex” by prohibiting puberty blockers or hormone replacement therapy for the purposes of allowing young people to live as an “identity inconsistent with the minor’s sex.”

The Department of Justice, Lambda Legal and the American Civil Liberties Union, who petitioned the Supreme Court to hear the case, have argued that Tennessee’s law amounts to sex discrimination because it specifically bars transgender youth from these medications while allowing cisgender youth to undergo the same treatments for other conditions, such as early puberty.

“This case contains some of the worst leaning into sex stereotypes that I’ve ever seen in a statute,” said Sasha Buchert, the director of the nonbinary and transgender rights project at Lambda Legal, the oldest LGBTQ+ law firm in the U.S. “It’s clearly a sex-based consideration because this is the same care that [they’re] just banning for trans people. But even further, there is this gender conformity aspect to the statute, which I think is implicit in all of these bans that we’ve seen. It’s just that Tennessee didn’t want to hide it.”

Tennessee has argued that the law does not specifically target trans people, although the state acknowledges that the ban sets “age- and use-based limits” on puberty blockers, hormones and surgeries for the “purpose of gender transition.” (Gender-affirming surgeries are not an issue in the Supreme Court case, however, as a district court threw out a challenge to those procedures.)

The law has faced legal challenges since the Tennessee legislature first passed it in March 2023. One month later, the ACLU filed a lawsuit on behalf of a trans teen identified as L.W., two other families of trans youth, and a Memphis-based doctor. The DOJ then joined the suit.

That summer, a district court found that the ban likely violated the U.S. Constitution and issued a preliminary injunction on parts of the law regarding puberty blockers and hormones. Tennessee’s attorney general, Jonathan Skrmetti, appealed the decision to the U.S. Court of Appeals for the 6th Circuit, which overturned that ruling. The Biden administration then asked the Supreme Court to review this case, arguing that any ban on trans health constitutes sex discrimination.

Since the Supreme Court only took up the Biden administration’s appeal, the court will not be weighing in on the question of whether the state law violates the “fundamental right of parents” to make medical decisions for their children, which is a central question in a separate lawsuit, L.W. v. Skrmetti.

The outcome of United States v. Skrmetti will provide much-needed legal clarity for trans youth and their families amidst an increasingly anti-trans political climate. Twenty-six states have passed laws restricting health care providers from prescribing puberty blockers and hormones, as well as performing surgeries on transgender youth.

Lower courts across the country have handed down conflicting rulings when these laws have been challenged. By and large, district court judges have attempted to block these bans, finding them unconstitutional after applying “heightened scrutiny” — a high legal standard used in civil rights cases that forces the government to prove a vested interest in the application of the law. Appeals court judges, on the other hand, have typically used “rational basis,” a lower form of review, when overturning previous injunctions of these bans.

Chase Strangio, the co-director of the ACLU’s LGBTQ and HIV Project, said on a press call Monday that if the Supreme Court rules in favor of Tennessee, it could “erode protections when it comes to sex-based discrimination,” especially in the context of medical care, long term. Strangio, the first trans lawyer to argue before the Supreme Court, is set to deliver a 15-minute oral argument on behalf of the three families of trans youth and the Memphis-based doctor on Wednesday.

However, if the Supreme Court rules as the district courts have by applying “heightened scrutiny,” then it will determine that bans on trans health care constitute sex discrimination, similar to how the high court determined in the Bostock v. Clayton County case that discrimination against trans employees is also sex discrimination.

“This isn’t just about health care,” Buchert said. “This is about a view that the state has of what normativity is — about how someone should be in the world existentially. It’s not just preventing care, there’s a clear philosophical purpose that is to force people to live consistent with what they view as the appropriate sex.”

There is a body of scientific evidence to show that puberty blockers and hormone replacement therapy substantially reduce gender dysphoria in adolescent patients, dozens of medical associations argued in briefs submitted to the Supreme Court in September. Doctors, medical groups, LGBTQ+ advocates, Democrats, Republicans and trans individuals have submitted briefs on the efficacy of gender-affirming care to alleviate dysphoria and prevent suicide.

However, Tennessee’s brief to the court is skeptical of gender-affirming care. It argues that these medical interventions are “experimental” and claims that at one point a Tennessee hospital, Nashville’s Vanderbilt University Medical Center, began providing trans health care in order to “make a lot of money.” The brief discusses at length how certain “media reports” about Vanderbilt providing gender-affirming care to minors exposed the hospital’s true intentions.

It is not clear what “media reports” the brief is referring to. However, the hospital first came under scrutiny in September 2022, when conservative political commentator Matt Walsh made a series of posts on social media accusing it of opening its trans clinic to turn a profit and criticizing its treatments for trans youth.

Later that month, Skrmetti announced that his office had opened an investigation into the clinic, demanding hundreds of patient medical records, as well as information about Vanderbilt’s employees and volunteers. In the aftermath of the investigation, a health care worker at the clinic told HuffPost that the medical center canceled appointments for certain surgeries for cisgender youth that currently do not fall into the category of trans health care but could be seen as “pathways to gender affirmation.”

United States v. Skrmetti comes at a pivotal time for trans rights in the U.S. President-elect Donald Trump has promised to “stop” gender-affirming care for minors nationwide, which he has equated to “child abuse” and “sexual mutilation.” The incoming president has also appointed Russell Vought, the co-author of Project 2025, as the director of the Office of Management and Budget. Project 2025, the blueprint for a second Trump term, includes dozens of policies that erase federal protections for LGBTQ+ people, including allowing Medicare and Medicaid to deny coverage for gender-affirming care and removing trans-inclusive protections from Title IV.

Jasmine Beach-Ferrara, the executive director of the Campaign for Southern Equality, an organization that has helped hundreds of families of trans youth travel out of state in light of these bans, said that communities are figuring out how to get the care they need in the immediate short term.

“We’re thinking about what can we do today? What can we do tomorrow?” she said. “How can we be prepared if a ruling like that does come down next summer and bans go into effect?”

State bans have imperiled thousands of trans youth, many of whom have had to travel hundreds of miles to continue care.

Harleigh Walker, a 17-year-old trans girl, and her father have had to travel 200 miles from Auburn, Alabama, to another state in order for her to make telehealth visits and continue receiving estrogen. Alabama’s ban went into effect in January, almost two years after the state legislature passed the law.

Harleigh has spent much of her teenage years obsessing over her school’s debate team and collecting vinyl records. She has also become an advocate, meeting with Vice President Kamala Harris as well as testifying to the U.S. Senate about her experiences and dispelling misinformation about her health care.

She told HuffPost that she has known she was trans since she was 10 years old, after resonating with videos of Gigi Gorgeous, a trans Canadian YouTuber. In April 2022, Harleigh and her family met with Alabama lawmakers to share how being able to access puberty blockers, and later estrogen, helped her become the girl she always knew she was. However, when the state became the second to ban gender-affirming care for youth that year, she felt betrayed by her representatives — and she now worries about how the Supreme Court’s decision could impact her future.

“I was pretty heavily bullied for being trans,” Harleigh said about her middle school years. “But then I built up confidence in who I was. I think there’s been a transition from being bullied by my peers to being bullied by lawmakers and adults.”

Harleigh plans to pursue a degree in law and one day go into politics. Though her father, Jeff Walker, is a huge fan of Auburn University in Alabama, the family understands that she will likely attend college out of state, as Alabama’s ban applies to anyone under 19.

“We had some time as a family to figure out what was best for her and how to support her on her journey,” Jeff Walker said, speaking in a room flanked by Auburn flags and signage. “It’s gut-wrenching to see what is said about the trans community or parents of trans children. And as a dad, it’s really hard to take.”

Brian Williams, the father of the teen identified as L.W., said during the press call Monday that his family came to every medical decision together and sought out the advice of other family members, patients they knew, and doctors.

After nine months of consultations, L.W. began puberty blockers at 13. Now 16 years old, L.W. is busy making her own music, designing video games, and looking ahead at college. Last year, she said that she’s fighting Tennessee’s law because “I know how important this care is for tens of thousands of transgender youth like me.”

Today, more than 90% of trans teenagers live in states that have passed laws restricting trans rights in some way: the ability to access health care, participate in sports, use school bathrooms, or use the correct pronouns in school. An estimated 113,900 trans youth live in states that have restricted transition-related care for minors, according to the Williams Institute at the UCLA School of Law.

Over the last two years, HuffPost has spoken with dozens of families of trans youth and trans adults who live in states with various kinds of bans on gender-affirming care. These restrictions have created a culture of fear, forced families to travel hundreds of miles out of state, and forced some adults to stockpile their hormones or forgo transition altogether.

Legal and medical experts alike worry that a decision against the plaintiffs could have widespread implications beyond trans youth. Advocates worry that the case could call into question the future of legal challenges around sex discrimination, wreak havoc on health care overall and make it more challenging for trans adults to access health care on state insurance plans.

Morissa Ladinsky, a pediatrician and professor at the University of Alabama at Birmingham, said that the impact of these bans on her patients has been extremely difficult. Even if they’re able to travel to receive care, young trans people are facing sleep issues, anxiety, and academic decline from the fear produced by these bans. Ladinsky said that one of the biggest misconceptions she has seen about health care for young trans people is around the timeline and thoroughness of the care.

“This is evidence-based health care that’s been in place for decades in this country. It is individualized and optimized for each patient,” she said, noting that youth and their families meet with medical providers, including psychologists and endocrinologists, as well as chaplains.

But states are losing medical professionals over restrictions to care, Ladinsky said. Alabama has experienced a physician shortage in the wake of its ban on gender-affirming care and the end of federal abortion protections. Medical professionals have similarly left states like Tennessee, Florida and Texas, which have passed their own bans on reproductive and trans health care.

“There’s a downstream fallout from these bans that affects the health of the people in my state,” said Ladinsky, who has worked in pediatric medicine for 30 years and opened Alabama’s first pediatric gender clinic in 2015. “Doctors are not coming to Alabama, and it is unequivocal that the downstream consequences of some of these health care bans or even fears of deepening health care bans are very real, very prescient, and may be driving physicians away from states where they’re sorely needed.”