Reflections on the Supreme Court’s Decision Upholding a Ban on Gender-Affirming Care for Trans Youth 

The U.S. Supreme Court last week held that Tennessee’s ban on gender-affirming care for transgender minors does not violate the federal Constitution. State Court Report spoke with D Dangaran, the director of gender justice at Rights Behind Bars, about what U.S. v. Skrmetti means, how the trans rights and abortion rights movements are similar, and where the trans rights movement goes from here. This interview has been edited for brevity and clarity.

Tell us about the Skrmetti decision.

The threshold question in Skrmetti was what standard of review to apply to an equal protection claim brought by youth challenging a Tennessee law banning gender-affirming care. Specifically at issue was hormone therapy, like puberty blockers.

The plaintiffs argued that the law classified people based on sex and so should receive heightened scrutiny — at the intermediate scrutiny level.

But a majority of the Court determined that gender dysphoria was the linchpin, not sex — even though gender dysphoria is a diagnosis that is 100 percent linked to one’s trans status. The Court said the law prohibits giving hormone therapy to minors for certain medical uses, here, gender dysphoria, regardless of a minor’s sex.

A distinction based on gender dysphoria only receives rational basis review. That means any plausible reason that a government has for creating the classification in question will suffice.

Applying rational basis view, the majority then held that this law, including civil penalties against doctors who decide to prescribe gender-affirming care, is permitted based on the reasons that the state of Tennessee provided.

What is the real-life impact of this ruling on trans kids and trans people across the country?

There are 3,000 trans youth in Tennessee, according to the facts presented in this case. There are probably more than that, they just don’t fill out the surveys. Those trans youth are now unable to receive care for this medical use — treating gender dysphoria. Folks would need to seek care out of state.

Many studies have shown that the medical care that’s been banned by Tennessee reduces depression, anxiety, and suicidality. When states pass anti-trans legislation specifically targeting youth and courts uphold such laws, the rates of calls to suicide prevention hotlines skyrocket. But on the same day that Skrmetti issued, the Trump administration stated that federal funding for the Trevor Project, one of the major suicide hotlines for LGBQT youth, will cease in 30 days. Just hearing about this decision will make trans and other queer youth experience extreme distress. So what I’m most worried about goes beyond Tennessee. This decision could increase instances of suicide.

That’s why many trans people feel like this kind of legislation, and the Supreme Court allowing it to stand, really is killing the trans community.

Are the effects of the ruling limited to trans youth?

No. That’s a really important thing to realize. Because gender dysphoria is a permissible classification for denying care, that extends to health care for adults, too.

This gives states a green light to either ban insurance coverage for gender dysphoria or totally ban the provision of care for gender dysphoria, even for adults. There are some states that have already started to do that. Alabama and Nebraska have passed laws that say people 19 years old and under cannot receive certain forms of gender-affirming care. It’s going to be much harder post-Skrmetti to challenge any bans on medical care for those with gender dysphoria.

What legal strategies should litigants challenging such bans consider now?

There is hope statutes like Tennessee’s could be successfully challenged under the Americans with Disabilities Act, or ADA. Skrmetti could actually help future ADA claims because of how clearly the Court said that the law was discriminating based on gender dysphoria. If the Court accepts that gender dysphoria is a disability, statutes like these are unlawful under the ADA. Discrimination on gender dysphoria may not get equal protection, but the whole point of the ADA is to bring protection to areas the equal protection clause does not reach. I think that that’s where the movement could be headed.

Ironically, the judge in the Sixth Circuit Court of Appeals who wrote the decision in Skrmetti that went up to the Supreme Court was Jeffrey Sutton. He wrote a book called 51 Imperfect Solutions, which points out that state supreme courts are not bound to follow federal constitutional law when interpreting their state constitutions. Advocates should bring state constitutional challenges to these laws.

In what ways might state constitutions provide protections beyond what the federal Constitution does in this context?

Even if the language of a state constitution’s Equal Protection Clause is a carbon copy of the 14th Amendment, the state has the right to construe it differently than the Supreme Court. You could bring a claim that looks just like the one in Skrmetti but based on the state constitution and the state supreme court could say, “We’re interpreting our constitution to not allow this kind of discrimination.”

There are takeaways for trans rights in the marriage equality fight. Advocates got multiple wins in state court, saying it would be discriminatory to prevent same-sex marriage. By the time it reached the U.S. Supreme Court as a federal claim there had been a groundswell of momentum in support of marriage equality. The Supreme Court could see that was where the country was.

There have been successes in some state courts challenging bans on gender-affirming care, but too many of these cases have been brought in federal court. We could benefit from a methodical, state-by-state approach.

Besides equal protection, there are other state constitutional provisions that could apply to laws that discriminate against trans people, some that don’t even appear in the federal Constitution. The right to privacy, for example, has been shut down by this Supreme Court. But some state constitutions protect the right to privacy or bodily autonomy.

Do you see parallels between the movements to secure abortion care and trans care?

The Supreme Court said in Dobbs that abortion bans are allowed and now in Skrmetti that states can ban trans health care. I’ve been happy to see a lot of solidarity between the reproductive justice movement and the trans rights movement. I do think that a lot ties the two.

In terms of legal strategy, advocates realize that the federal courts are not the place to bring challenges to laws that discriminate against trans people. Just like a lot of reproductive rights litigation shifted to state courts, under state constitutions, I think we’ll see more trans rights cases in state courts. My big concern, though, is what happens for those who live in red states, where state courts will be less willing to extend protections beyond what the federal Constitution grants.

A lot of people, including lawyers, are becoming more aware of the need to do local-level organizing and policy work. The court system might not be the right place for us right now.

The trans advocacy community can learn from those who have been trying to help people get abortions post-Dobbs. That could include mutual aid networks to take people out of state to receive care. The challenge with getting hormone therapy out of one’s own state is the need for follow-up appointments and labs. In that way, busing people across state lines for trans care is trickier than for abortion care, which can typically be done in one visit.

We’ve seen doctors who treat women from states with abortion bans being prosecuted in the ban state. There is a possibility of that happening to doctors who treat trans youth from states with bans on gender-affirming care. I hope for more sanctuary cities and states to pass shield laws for doctors providing care to out-of-state patients. Those exist in the abortion context.

You represent incarcerated people seeking gender-affirming care behind bars. Does this decision impact your clients?

Yes. I have two clients — one is a trans woman and one is a trans man — who have been denied care in prison that cis gender people have been able to get and have sought medical care using equal protection arguments.

I represented a trans man who said other people in his facility — he is housed with cis women — were able to get a mastectomy to treat breast cancer. Of course, cancer is not the same as gender dysphoria. But they also were able to get breast augmentation surgery after the mastectomy. Breast augmentation is no longer treating breast cancer. It’s just helping to make them feel whole because they don’t feel comfortable in a body without breasts. My client said, “I have that same need. I don’t feel whole in my body. I need my breasts to be removed so I can feel like me.”

One of my cases is in the Fifth Circuit Court of Appeals. I could imagine the court now saying there is absolutely no hope for an equal protection argument for an adult seeking gender-affirming surgery.

How do you move forward after a setback like this?

I am grateful for the trans community. I recently felt uplifted by the thought that this community has endured. We’ve sought and held onto joy. We’re doing this because we have the self-awareness and the consciousness to be open with ourselves and others about how we actually feel about bodies.

And that body autonomy and body liberation is so beautiful and so exciting. These “culture wars” are, to me, a continued colonization of how other people live, from a white Christian hegemonic power source outward to others. There are coalitions to be built in resisting that.

Suggested Citation: Kathrina (Kasia) Szymborski Wolfkot (interview with D Dangaran), Reflections on the Supreme Court’s Decision Upholding a Ban on Gender-Affirming Care for Trans Youth, Sᴛᴀᴛᴇ Cᴏᴜʀᴛ Rᴇᴘᴏʀᴛ(Jun. 25, 2025), https://statecourtreport.org/our-work/analysis-opinion/reflections-supreme-courts-decision-upholding-ban-gender-affirming-care