The U.S. Supreme Court’s Decision on Trans Healthcare Is Rippling Through State Courts 

Earlier this month, a North Dakota trial court upheld the state’s ban on gender-affirming care for trans minors. It is among the first state courts to rule on the issue since the U.S. Supreme Court’s June decision that a similar ban in Tennessee did not violate the U.S. Constitution’s guarantee of equal protection.

In T.D. v. Wrigley, a North Dakota doctor, three trans children, and the children’s parents challenged the state’s 2023 so-called Health Care Law that bans gender-affirming care for trans minors. They alleged the law was unconstitutional under several provisions of the North Dakota Constitution, including its equal protection clause, similar to the federal constitutional claim against the Tennessee law challenged in the U.S. Supreme Court’s United States v. Skrmetti. And just like in Skrmetti, the North Dakota court upheld the Health Care Law by finding it “limits medical treatment based upon the purpose of that treatment, not based upon the sex of the person seeking the treatment.”

There are many reasons this decision is troubling to people who care about dignity and equality for trans people. For one, given the persistence with which state courts interpret their state constitution in lockstep with the federal counterpart, Skrmetti offers a template for rejecting equal protection challenges to healthcare bans. Case in point: Although the North Dakota case was brought under the state constitution, the court relied heavily on Skrmetti, explaining that, while there is a history of the state constitution’s equal protection clause being interpreted differently than the federal Constitution’s, recent cases from the North Dakota Supreme Court have “align[ed] its equal protection analysis with that of the United States Supreme Court.”

This decision also brings to the surface something that was obscured, but still present, in Skrmetti: the incorporation of transmedicalism into legal doctrine. Broadly, transmedicalism refers to the assumption that trans identity is inherently medical. For example, one variation of transmedicalism is the belief that being trans requires a full medical transition to the anatomy of the opposite sex from one’s birth sex. Another is the belief that a diagnosis of gender dysphoria is a prerequisite to being trans.

But in fact, gender dysphoria is simply one of a multitude of experiences that can, but do not have to, go along with being trans: While “transgender” is “an umbrella term for persons whose gender identity, gender expression or behavior does not conform to that typically associated with the sex to which they were assigned at birth,” “gender dysphoria” is more specifically defined as the “psychological distress that results from an incongruence between one’s sex assigned at birth and one’s gender identity.” Centering trans identity on a medical diagnosis is not just incorrect, it is also exclusionary, especially towards gender non-conforming individuals and other trans people who do not identify on the gender binary, and even to binary-identifying trans individuals who do not wish to fully medically transition.

To uphold the Health Care Law, the North Dakota court determined the law was subject to rational basis review — the most lenient standard courts use to assess the constitutionality of a law — even if it discriminates on the basis of transgender status. In doing so, the court conflated trans identity and gender dysphoria, allowing it to say that any discrimination based on trans identity that is present in the law merely stems from the law’s regulation of “medical treatment based upon the purpose of that treatment.” The court said that because gender dysphoria “is a condition that may go into remission or desist,” it is not an “immutable characteristic” that entitles trans individuals as a class to heightened scrutiny under the state constitution’s equal protection clause.

There are two major flaws in this logic. First, it misinterprets the medical evidence. The court claimed its statements about immutability were supported by the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. But the court seemingly ignores the many ways in which the manual’s description of gender dysphoria caveats its discussion of potential remission or desistance. For example, the word “remit” appears only once, in the context of a discussion of the lack of any studies regarding the adolescent and adulthood experiences of children who experienced “childhood gender variance.” Within this context, “remit” is used in a very narrow sense, referring solely to the proposition that some children who experience gender dysphoria may experience remission as they grow older and that, of those who do, their dysphoria can still recur later in life. More dramatically, the manual only uses “desist” twice, both times while explaining that some children who experience gender dysphoria may go through “periods” where their dysphoria “desists or is denied,” explicitly recognizing that often so-called desistance is a form of self-denial, with feelings of dysphoria later “recurring.” Additionally, while the court heard testimony about high rates of desistance among “cross-gender identified” children, the studies behind those statistics have been largely debunked, leading to suggestions that the concept of desistance should be entirely removed from clinical practice and research around gender dysphoria.

Second, and more importantly, this logic is unadulterated transmedicalism. The justification the court gives for its conflation of trans identity and gender dysphoria is that “a diagnosis of gender dysphoria is a prerequisite to receiving the medical interventions banned by the Health Care Law.” That is not what the law says. The statutory language prohibits gender-affirming treatment based solely on “if a minor’s perception of the minor’s sex is inconsistent with the minor’s sex.” This language omits the “psychological distress” component necessary to a gender dysphoria diagnosis — and thus sweeps in a much broader swath of people who will be denied care. In fact, the statutory definition is much closer to the broad definition of transgender than it is to the more specific definition of gender dysphoria.

Analyses like that in Wrigley are part of Skrmetti’s early legacy. Skrmetti found that Tennessee’s ban on the provision of puberty blockers and hormone treatment to trans minors did not discriminate on the basis of sex or transgender status, but on age and medical diagnosis. “The law does not prohibit conduct for one sex that it permits for the other,” Chief Justice John Roberts explained in the Court’s majority opinion. “Under [Tennessee’s law], no minor may be administered puberty blockers or hormones to treat gender dysphoria, gender identity disorder, or gender incongruence; minors of any sex may be administered puberty blockers or hormones for other purposes.”

While such logic may at first seem to subvert transmedicalist ideology by treating gender dysphoria and trans identity as distinct, it is actually an inversion of transmedicalism that has the same negative effect on trans people. Like the traditional transmedicalism reflected in the North Dakota court’s opinion, the Supreme Court’s approach defines trans identity solely in relation to gender dysphoria. Rather than insisting that gender dysphoria is necessary for someone to be trans, the Court insists that gender dysphoria is not sufficient for someone to be trans. In other words, because only some trans people may experience and seek treatment for gender dysphoria, a law banning such treatment does not implicate trans identity. As Roberts explains it, “Although only transgender individuals seek treatment for gender dysphoria, gender identity disorder, and gender incongruence — just as only biological women can become pregnant — there is a ‘lack of identity’ between transgender status and the excluded medical diagnoses.” But even though not all trans people experience gender dysphoria, gender dysphoria is intimately linked to trans identity. Claiming that gender dysphoria is a free-standing medical diagnosis ignores reality just as much as — and is just as exclusionary as — traditional transmedicalist beliefs. 

It is possible that this emergence of transmedicalism in court opinions will stay confined to cases involving bans on gender-affirming care. After all, the distinction between trans identity and gender dysphoria is more relevant in that context than, say, in challenges to laws excluding trans girls from participating in girls’ sports. However, any appearance of transmedicalism in legal thought reinforces societal stigma around trans identity and gender non-conformance, including the perception that trans identity is a pathology that needs to be corrected or that trans people are some sort of anomaly or curiosity separate and apart from “normal” people. State courts grappling with issues of trans rights in a post-Skrmetti world should avoid relying on transmedicalist tropes that demean and demonize trans people.

Morgan Munroe is a student at NYU Law School. She previously participated in the Brennan Center’s Public Policy Advocacy Clinic.

Suggested Citation: Morgan Munroe, The U.S. Supreme Court’s Decision on Trans Healthcare Is Rippling Through State Courts, Sᴛᴀᴛᴇ Cᴏᴜʀᴛ Rᴇᴘᴏʀᴛ(Oct. 29, 2025), https://statecourtreport.org/our-work/analysis-opinion/us-supreme-courts-decision-trans-healthcare-rippling-through-state-courts