Supreme Court signals it will uphold 'state-sanctioned discrimination' in transgender care

Attorneys who argued against Tennessee's ban on gender-affirming healthcare at the U.S. Supreme Court on Wednesday expressed hope that the court's nine justices will take "the opportunity to affirm the essential freedom and equality of all people before the law," while reports indicated that the right-wing majority is inclined to uphold the ban.

"Every day this law inflicts further pain, injustice, and discrimination on families in Tennessee and prevents them from receiving the medical care they need," said Lucas Cameron-Vaughn, staff attorney at the ACLU of Tennessee, which represented three families and a physician. "We ask the Supreme Court to commit to upholding the promises of the U.S. Constitution for all people by putting an end to Tennessee's state-sanctioned discrimination against trans youth and their families."

The law, S.B. 1, which was passed in March 2023, bars medical providers from prescribing puberty-delaying medications, other hormonal treatment, and surgical procedures to transgender minors and youths with gender dysphoria.

The Supreme Court case, United States v. Skrmetti, applies only to the ban on puberty blockers and hormonal therapy for minors; a lower court found the plaintiffs did not have legal standing to challenge the surgery ban.

The ACLU, the ACLU of Tennessee, Lambda Legal, and a law firm were joined by the Biden administration in arguing that Tennessee allows doctors to prescribe puberty blockers and other hormonal treatments for youths with congenital defects, early puberty, diseases, or physical injuries.

As such, said the plaintiffs, Tennessee's ban for transgender and nonbinary youths violates the U.S. Constitution's 14th Amendment, which guarantees equal treatment under the law.

"My heart—and the heart of every transgender advocate fighting this fight—is heavy with the weight of what these laws mean for people's everyday lives."

The court's three liberal justices—Justices Sonya Sotomayor, Elena Kagan, and Ketanji Brown Jackson—all indicated they believed Tennessee has tried to classify people according to sex or gender with the law.

"One of the articulated purposes of this law is essentially to encourage gender conformity and to discourage anything other than gender conformity," said Kagan. "Sounds to me like, 'We want boys to be boys and we want girls to be girls,' and that's an important purpose behind the law."

Matthew Rice, the lawyer representing Tennessee in the case, claimed the state simply wants to prevent "regret" among minors, and the court's six conservative justices signaled they were inclined to allow Tennessee to ban the treatments—which are endorsed by the American Academy of Pediatrics and other top medical associations.

Chief Justice John Roberts said the nine justices should not overrule the decision made by lawmakers representing Tennessee residents, considering there is debate over the issue, and pointed to changes some European countries have made to their gender-affirming care protocols for minors.

Representing the Biden administration, U.S. Solicitor General Elizabeth Prelogar acknowledged that there has been debate about gender-affirming care in the U.S. and abroad, but pointed out that countries including the U.K. and Sweden have not outright banned treatment.

"I think that's because of the recognition that this care can provide critical, sometimes lifesaving benefits for individuals with severe gender dysphoria," she said.

Following the arguments, plaintiff Brian Williams, who has a 16-year-old daughter in need of gender-affirming care, addressed supporters who had assembled outside the Supreme Court.

"Tennessee's ban on gender-affirming medical care is an active threat to the future my daughter deserves," said Williams. "It infringes not only on her freedom to be herself but on our family's love for her. We are not expecting everyone to understand everything about our family or the needs of transgender young people like our daughter. What we are asking for is for her freedom to be herself without fear. We are asking for her to be able to access the care she needs and enter adulthood knowing nothing is holding her back because of who she is."

Sotomayor said there is "very clear" evidence "that there are some children who actually need this treatment."

A 2022 study led by researchers at the University of Washington found that transgender and nonbinary youths aged 13-20 were 60% less likely to experience moderate or severe depression and 73% less likely to be suicidal after receiving gender-affirming care.

Prelogar asked the justices to "think about the real-world consequences of laws like S.B. 1," highlighting the case of a plaintiff identified as Ryan Roe.

Roe had such severe gender dysphoria that "he was throwing up before school every day," said Prelogar. "He thought about going mute because his voice caused him so much distress. And Ryan has told the courts that getting these medications after a careful consultation process with his doctors and his parents, has saved his life."

"But Tennessee has come in and categorically cut off access to Ryan's care," she added. "This law harms Ryan's health and the health of all other transgender adolescents for whom these medications are a necessity."

Tennessee is home to about 3,100 transgender teenagers, and about 110,000 transgender youths between the ages of 13-17 live in the 24 states where gender-affirming care is restricted.

More than 20 states have laws that could be impacted by the court's ruling in United States v. Skrmetti.

"My heart—and the heart of every transgender advocate fighting this fight—is heavy with the weight of what these laws mean for people's everyday lives," said Chase Strangio, co-director of the ACLU's LGBTQ & HIV Project. "But I also know that every out trans person has embraced the unknown in the name of living free from shame or the limits of other people's expectations."

"My heart aches for the parents who spent years watching their children in distress and eventually found relief in the medical care that Tennessee now overrides their judgment to ban," said Strangio. "Whatever happens today, tomorrow, and in the months and years to come, I trust that we will come together to fight for the realized promise of our Constitution's guarantee of equal protection for all."

A ruling in the case is expected in June.