In a major victory for Republican leaders in states such as Florida, the U.S. Supreme Court on Wednesday upheld a Tennessee law that bars doctors from providing puberty blockers and hormone therapy to minors to treat gender dysphoria.
The closely watched 6-3 ruling came amid a long-running legal battle about a similar ban that Florida approved in 2023.
The ruling dealt only with Tennessee's restrictions on treatment for children. However, the Campaign for Southern Equality, an LGBTQ-advocacy group, said 27 states have passed bans or restrictions on such treatment since 2021 and the decision means they will "remain in place."
That includes Florida, where Attorney General James Uthmeier applauded high count's decision.
"Florida was the first state to pass rules protecting children from these horrible, mutilating practices through our state medical board, and those rules were later passed into law," Florida Attorney General James Uthmeier said in a post on X. "This is a big win for common sense and an even bigger win for children. Let kids be kids!"
The ruling came about five months after a panel of the 11th U.S. Circuit Court of Appeals heard arguments in a battle about a similar Florida law and regulations that Gov. Ron DeSantis and the GOP-controlled Legislature made a priority in 2023. The case has remained pending at the Atlanta-based appeals court.
In addition to preventing minors from beginning to receive puberty blockers and hormone therapy for treatment of gender dysphoria, the Florida restrictions allowed only physicians — not nurse practitioners — to approve hormone therapy for adults and barred the use of telehealth for new prescriptions. Opponents have argued the restrictions reduced access to hormone therapy for adults.
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In 2024, U.S. District Judge Robert Hinkle ruled that the Florida restrictions were unconstitutional, but a panel of the Atlanta-based appeals court issued a stay of Hinkle's decision. The stay allowed the restrictions to be in effect while the underlying appeal of the decision continued,
It was clear during the January hearing that appeals court judges were watching the U.S. Supreme Court on the Tennessee law. Judges Adalberto Jordan and Andrew Brasher raised questions during the hearing about whether the panel should put the Florida case on hold while the Supreme Court considered the similar dispute.
Florida and other Republican-led states in recent years have approved numerous laws and regulations focused on transgender people. One of the highest-profile issues has been restricting use of puberty blockers and hormone therapy for minors.
"It's a deeply disappointing decision — one that history will judge harshly," the nonprofit Equality Florida said in a statement on its website. "Politicians have no place in the exam room. Parents, not lawmakers, should make medical decisions for their children.
"This ruling marks a dark chapter, but it's not the end of the story. Our families are not backing down. As we continue reviewing the decision with our national legal partners, one thing remains clear: We will keep showing up, speaking out and fighting for a future where every child has access to the care, support, and dignity they deserve."
Roberts rejects equal protection argument
Wednesday's majority opinion, written by Chief Justice John Roberts, rejected arguments that such restrictions violate equal-protection rights and pointed to the authority of legislatures to decide such issues.
"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. 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. Our role is not 'to judge the wisdom, fairness, or logic' of the law before us … but only to ensure that it does not violate the equal protection guarantee of the Fourteenth Amendment," Roberts wrote, partially quoting a legal precedent. "Having concluded it does not, we leave questions regarding its policy to the people, their elected representatives, and the democratic process."
Justice Sonia Sotomayor, taking issue with a legal standard used by the majority, said justices retreated from "meaningful judicial review" and abandoned "transgender children and their families to political whims." Sotomayor wrote that she dissented in "sadness."
"Transgender adolescents' access to hormones and puberty blockers (known as gender-affirming care) is not a matter of mere cosmetic preference," Sotomayor wrote. "To the contrary, access to care can be a question of life or death. Some transgender adolescents suffer from gender dysphoria, a medical condition characterized by clinically significant and persistent distress resulting from incongruence between a person's gender identity and sex identified at birth. If left untreated, gender dysphoria can lead to severe anxiety, depression, eating disorders, substance abuse, self-harm, and suicidality."
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Along with Roberts, the majority was made up of justices Clarence Thomas, Samuel Alito, Neil Gorsuch, Brett Kavanaugh and Amy Coney Barrett. Justices Elena Kagan and Ketanji Brown Jackson joined Sotomayor in dissent.
A major issue in the case was the appropriate level of scrutiny courts should apply to such laws.
The lowest level is known as rational basis review, and almost every law looked at that way is upheld. Indeed, the federal appeals court in Cincinnati that allowed the Tennessee law to be enforced held that lawmakers acted rationally to regulate medical procedures.
The appeals court reversed a trial court that employed a higher level of review, heightened scrutiny, which applies in cases of sex discrimination. Under this more searching examination, the state must identify an important objective and show the law helps accomplish it.
Roberts' 24-page majority opinion was devoted almost entirely to explaining why the Tennessee law, called SB1, should be evaluated under the lower standard of review. The law's restrictions on treating minors for gender dysphoria turn on age and medical use, not sex, Roberts wrote.
Doctors may prescribe puberty blockers and hormone therapy to minors of any sex to treat some disorders, but not those relating to transgender status, he wrote.
Some providers have stopped treatment already
Trump issued an executive order days into his second term that says the federal government must not support gender transitions for anyone under age 19.
Since then, some providers have ceased some treatments. For instance, Penn Medicine in Philadelphia announced last month it wouldn't provide surgeries for patients under 19.
The president of the American Academy of Pediatrics, Dr. Susan Kressly, said the organization is "unwavering" in its support of gender-affirming care and "stands with pediatricians and families making health care decisions together and free from political interference."
ALSO READ: Florida begins appeal of federal judge's ruling on gender-affirming care
Five years ago, the Supreme Court ruled LGBTQ people are protected by a landmark federal civil rights law that prohibits sex discrimination in the workplace. That decision is unaffected by Wednesday's ruling.
But the justices declined to apply the same sort of analysis the court used in 2020 when it found "sex plays an unmistakable role" in employers' decisions to punish transgender people for traits and behavior they otherwise tolerate. Roberts joined that opinion written by Gorsuch, who was part of Wednesday's majority.
There are about 300,000 people between the ages of 13 and 17 and 1.3 million adults who identify as transgender in the U.S., according to the Williams Institute, a think tank at the UCLA School of Law that researches sexual orientation and gender identity demographics.
Change in administration and opinion
When the case was argued in December, then-President Joe Biden's Democratic administration and families of transgender adolescents called on the high court to strike down the Tennessee ban as unlawful sex discrimination and to protect the constitutional rights of vulnerable Americans.
They argued the law violates the equal protection clause of the 14th Amendment in part because the same treatments that the law prohibits for transgender minors can be used for other purposes.
Soon after Trump took office, the Justice Department told the court its position had changed.
U.S. Attorney General Pam Bondi, who served in the role in Florida from 2011 to 2019, encouraged other states to follow Tennessee's lead "and enact similar legislation to protect our kids."
"I applaud (Wednesday) Supreme Court decision that allows states to protect vulnerable children from genital mutilation and other so-called 'gender-affirming care' that leaves children permanently disfigured and scarred," Bondi wrote in a post on X.
"This Department of Justice will continue its fight to protect America's children and parental rights. I encourage other states to follow Tennessee's lead and enact similar legislation to protect our kids.
Information from the Associated Press was added to this report.
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