Rational and prudent

America's highest court upholds the right of states to protect children from gender medicalisation

Photo by Drew Beamer on Unsplash

Trans-Atlantic

Laws restricting paediatric medical transition in 25 American states appear more secure following a US Supreme Court ruling that took into account the fact of regretful detransitioners and the evidence-driven shift to more cautious treatment in some European nations.¹

By a 6-3 majority in the case US v Skrmetti,² the court rejected the argument that Tennessee’s statutory ban on puberty blockers and cross-sex hormones for gender-distressed minors targeted patients according to biological sex, which would have required close judicial scrutiny of the law for any breach of the Constitution’s “equal protection” guarantee.

The 2023 Tennessee statute applies a penalty of $25,000 per violation, exposes healthcare providers to regulatory discipline, and creates a private right of legal action for a minor who is harmed by medical transition or for non-consenting parents.

The plaintiffs in the challenge to the law—three transgender-identifying minors, their parents and a doctor—were backed by the Biden administration’s Department of Justice, the American Civil Liberties Union and a bevy of LGBTQ lobby groups.

Writing the majority decision handed down on June 18, Chief Justice John Roberts said the Tennessee state ban did not target sex, but applied according to age (adults are unaffected) and medical treatment (hormonal treatment is banned for gender dysphoria or incongruence but not for the condition of precocious or premature puberty). The law was upheld as constitutional.

“The [Skrmetti] ruling effectively establishes a path forward for states to restrict practices their legislatures regard as harmful and inadequately regulated. A second-order effect, one can hope, is that the ruling will draw more attention to the flimsy evidence base, lack of reasonable clinical rationale, and ethical problems in the provision of these interventions to minors.”—commentator Leor Sapir, The Free Press, 18 June 2025

Treatment matters

Laws classifying people by sex attract closer judicial scrutiny in the US on the basis that they may reflect stereotypes or sweeping generalisations about male and female differences.

The challengers in Skrmetti argued that the Tennessee law classifies patients by sex because a biological female who identifies as male is denied puberty blockers and cross-sex testosterone to “live and present” as a male, whereas a non-trans biological male with precocious puberty or low testosterone can be given these hormone drugs supposedly for the same purpose.

But in its decision, the court said this argument “contorts” the meaning of the term medical treatment, which may involve one drug and various distinct indications.

The hormone suppression drugs in question, known as GnRHa, were originally used with prostate cancer or for precocious puberty, where a child begins sexual development well before peers.

In the 1990s and 2000s, Dutch clinicians began to use these puberty blockers to halt the naturally timed development of “juvenile transsexuals” in the hope they would grow up to “pass” as the opposite sex and enjoy better mental health than those who had transitioned as adult males and shown high rates of suicide after surgery incapable of undoing the effects of male puberty.

In Skrmetti, the US Supreme Court distinguished between these two quite different uses of puberty blockers.

“When, for example, a transgender boy³ (whose biological sex is female) takes puberty blockers to treat his gender incongruence, he receives a different medical treatment than a boy whose biological sex is male who takes puberty blockers to treat his precocious puberty,” the majority decision said.⁴

Since the statute distinguishes by diagnosis, not sex, the court applied the less onerous test that Tennessee simply had to show a “rational basis” for its law, which would require unelected judges to defer to democratically enacted policy.

The court held that the state “clearly meets” this test, and it noted the following findings and concerns put on the record by Tennessee’s legislature explaining its decision to ban gender medicalisation of minors—

• These hormonal treatments can lead to a minor “becoming irreversibly sterile, having increased risk of disease and illness, or suffering from adverse and sometimes fatal psychological consequences.”

• “[It is] likely that not all harmful effects associated with these types of medical procedures when performed on a minor are yet fully known, as many of these procedures, when performed on a minor for such purposes, are experimental in nature and not supported by high-quality, long-term medical studies.”

• “Minors lack the maturity to fully understand and appreciate the life-altering consequences of such procedures and … many individuals have expressed regret for medical procedures that were performed on or administered to them for such purposes when they were minors.”

• There is evidence that the conflict between sex and gender “can be resolved by less invasive approaches that are likely to result in better outcomes for the minor.”

The court said the need for state “legislative flexibility” in this field is reinforced by England’s 2024 Cass report and its verdict that the evidence base for paediatric medical transition is “remarkably weak.”

The judges also cited the decision by England’s National Health Service to confine puberty blockers to a proposed clinical trial and to review cross-sex hormone use for minors.

The majority court decision noted the 2020 conclusion by Finland’s health authorities—who led Europe’s shift to caution—that “gender reassignment of minors is an experimental practice”.

Also mentioned by the US judges were the 2020 UK systematic reviews showing the evidence base for youth gender clinics to be of “very low certainty”, and Sweden’s 2022 finding that the risks of puberty blockers and cross-sex hormones for minors outweigh the possible benefits.

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Video: Tennessee’s Attorney General Jonathan Skrmetti says the Supreme Court ruling is not political but reflects an international shift in policy driven by evidence

“This ruling confirms what whistleblowers, parents and detransitioners have been saying for years. These are not settled, safe or evidence-based practices. They are high-risk interventions being pushed on vulnerable children in the name of ideology.”—Gender clinic whistleblower Jamie Reed of the LGB Courage Coalition, 19 June 2025

Acceptance

One flashpoint in the Skrmetti case was Tennessee’s stated aim to encourage minors to “appreciate” rather than “become disdainful of” their biological sex.

This showed the state seeking to enforce conformity with biological sex by requiring “boys and girls to look and live like boys and girls,” according to the plaintiffs challenging the law.

However, the court said this argument failed because the statute showed no such “sex-based stereotyping”, and it was “not improper for the state to protect minors from procedures that ‘encourage them to become disdainful of their sex’—and thus at risk for serious psychiatric conditions.”

Tennessee had also cited the high rate of “desistance”⁵ among trans-identifying youth and the “tragic regret” of detransitioners as reasons to support the view that minors will benefit from more time to “appreciate their sex” before embarking upon irreversible, life-altering medicalisation of their healthy bodies.

“The Supreme Court’s strong decision today is a massive win in the fight to protect children from harmful gender ideology. Transgender treatments for minors are experimental medicine not backed by reliable evidence.”—Kristina Rasmussen, executive director of medical watchdog group Do No Harm, 18 June 2025

Not so civil rights

Two judges in the court majority cast doubt on dogmas of trans identity that underpin the movement’s narrative of a uniquely marginalised civil rights cause in need of special protection and guaranteed access to medical services.

In her concurring opinion, Justice Amy Coney Barrett endorsed the view that trans status should not qualify for the more vigilant judicial safeguarding that can strike down laws dividing people by race and sex.

She said “transgender status is not marked by the same sort of ‘obvious, immutable, or distinguishing characteristics’ as race or sex.

“The plaintiffs [in the Skrmetti case] began to experience gender dysphoria at varying ages—some from a young age, others not until the onset of puberty.

“Meanwhile, the plaintiffs acknowledge that some transgender individuals ‘detransition’ later in life—in other words, they begin to identify again with the gender that corresponds to their biological sex.

“Accordingly, transgender status does not turn on an “immutable . . . characteristi[c].”

“How the Transgender Rights Movement Bet on the Supreme Court and Lost. The inside story of the case that could set the movement back a generation.”—Investigative reporter Nicholas Confessore, The New York Times, 19 June 2025

This is not Rosa Parks redux

In his decision, Justice Samuel Alito stressed that Tennessee’s law does not amount to some sweeping repression of trans identity.

“[It] targets only the experimental medical procedures that the legislature found to be unsupported and dangerous,” he said.

“It does not regulate any other behavior in which minors might engage for the purpose of expressing their gender identity. It says nothing at all about names, pronouns, hair styles, attire, recreational activities or hobbies, or career interests.

“And the law’s restrictions apply only to the treatment available to minors.”

He also argued that trans status does not come with a history of onerous discrimination of the kind warranting close judicial scrutiny of laws affecting those marked out by that identity.

“Although transgender persons have undoubtedly experienced discrimination, the plaintiffs and their many amici [supportive LGBTQ lobby groups] have not been able to show a history of widespread and conspicuous discrimination that is similar to that experienced by racial minorities or women,” Justice Alito said.

“There is no evidence that transgender individuals, like racial minorities and women, have been excluded from participation in the political process. And despite the small size of the transgender population, the members of this group have had notable success in convincing many lawmakers to address their problems.”

Like Justice Barrett, he argued that the multitude of trans and other “gender identities” makes for a diverse and amorphous group, militating against its eligibility for special judicial protection of the kind conferred on the civil rights category of race.

“A ruling like this does not change the fundamental fact that transgender youth exist, [or that] their lives are improved when they can access care and are harmed whenever the government comes between them and the professional experts trained to provide them this care.”—Joint statement by the US Professional Association for Transgender Health and the World Professional Association for Transgender Health, 18 June 2025

Fake consensus

In his separate, concurring decision, Justice Clarence Thomas sharply criticised the familiar US refrain that gender medicalisation of minors is backed by “the overwhelming consensus of the [American] medical community.”

In fact, he said, “The treatments at issue are subject to a rapidly evolving debate that demonstrates a lack of medical consensus over their risks and benefits.”

The judge queried the integrity of that supposed bedrock authority, the World Professional Association for Transgender Health (WPATH), and cited explosive court documents (filed in a separate case) suggesting its leadership had abruptly abandoned minimum ages on trans surgery for minors in their 2022 treatment guideline following pressure from the Biden administration.

Justice Thomas also noted the conclusion of England’s Cass review that WPATH was the central node of a network of like-minded, low-quality treatment guidelines employing a pattern of circular referencing to create a false impression of consensus in favour of the “gender-affirming” worldview.

He said the Cass review observed that most of these guidelines around the world had “described insufficient evidence about the risks and benefits of medical treatment in adolescents” but nonetheless “went on to cite this same evidence to recommend medical treatments”.

He challenged the “transition or suicide” narrative of gender affirmationists, quoting the Cass review’s finding of no good evidence to support the claim that “hormone treatment reduces the elevated risk of death by suicide.”

Justice Thomas cited accounts of parents who felt they were subject to “emotional blackmail” when gender clinicians pressured them to agree to treatment by implying their children might attempt suicide if there were any deviation from the gender-affirming way.

He said that state policymakers “might reasonably question whether, under such conditions, parents’ consent is valid and consistent with ethical principles.”

“We detransitioners have been forever cemented into American history. Four years ago, nobody even knew we existed. Now, the Supreme Court knows who we are. The fight against gender ideology has been one of the most successful awareness campaigns in history.”—Detransitioner Chloe Cole, X/Twitter, 19 June 2025

A setback for eminence-based medicine

Justice Thomas said issues in the Skrmetti case supplied “good reasons to question the expert class here, as recent revelations suggest that leading voices in this area have relied on questionable evidence, and have allowed ideology to influence their medical guidance.

“Many prominent medical professionals have declared a consensus around the efficacy of treating children’s gender dysphoria with puberty blockers, cross-sex hormones and surgical interventions, despite mounting evidence to the contrary,” he said.

“They have dismissed grave problems undercutting the assumption that young children can consent to irreversible treatments that may deprive them of their ability to eventually produce children of their own.

“They have built their medical determinations on concededly weak evidence. And, they have surreptitiously compromised their medical recommendations to achieve political ends.

“This case carries a simple lesson—in politically contentious debates over matters shrouded in scientific uncertainty, courts should not assume that self-described experts are correct.”

Justice Thomas invoked the warning of the US Food and Drug Administration that the safety of a drug authorised for use with one medical condition cannot be generalised to other “off-label” uses. Puberty blockers are approved for use with precocious puberty but not for gender dysphoria or incongruence.

“To treat precocious puberty, puberty blockers are administered until the age appropriate for puberty; to treat gender dysphoria, however, puberty blockers are administered to stop puberty throughout the years it would normally occur,” he said.

“Research suggests that, aside from interrupting a child’s normal pubertal development, puberty blockers may lead to decreased bone density and impacts on brain development.”

The judge also pointed out the research finding that the “vast majority” of trans-identifying children begun on puberty blockers—some as young as age 8—proceed to irreversible cross-sex hormones meant to be taken lifelong. For this reason, he said, the risks of blockers cannot be weighed in isolation from those of hormones.

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Socials: US Vice-President JD Vance trolled progressives by launching a new Bluesky account and posting a key section of Justice Thomas’s evisceration of gender experts

More kids, more doubts

Justice Thomas said: “[T]he number of children identifying as transgender has surged, and medical professionals have increasingly expressed doubts over the quality of evidence supporting the use of puberty blockers, cross-sex hormones and surgery to treat them.

“Over the past several years, public health authorities in different [European] countries have concluded that these sex-transition treatments are experimental in practice, and that the evidence supporting their use is of ‘very low certainty’, ‘insufficient’ and ‘inconclusive’.”

In response to the claim of the gender-affirming lobby that no European country has applied a blanket ban excluding “medically necessary” treatment of minors, Justice Thomas argued that the category of “medical necessity” has been stretched to the point where state governments might reasonably opt for bans with no exceptions at all.

He cited WPATH’s guideline assertion that surgery is medically necessary for “eunuchs” who “wish to eliminate masculine physical features, masculine genitals, or genital functioning.” He described in some detail the radical procedures to fashion a pseudo-penis for a female and a pseudo-vagina for a male.⁶

“These surgical interventions are irreversible, entail significant complications, and, in some cases, result in permanent infertility,” he said.

Justice Thomas posed the question whether gender medicalisation of minors can ever be ethical, and emphasised the fact that state governments have an interest in protecting the integrity of the medical profession.

He also asked how young children can give informed consent to treatments with uncertain long-term effects and known risks to sexual function and fertility.

“The capacity to knowingly consent to these medical interventions requires a level of comprehension about science, sex and fertility that state legislatures could determine a child is unlikely to possess,” he said.

The judge quoted from a leaked recording of a WPATH panel talk in which an endocrinologist said—

“… the thing you have to remember about kids is that we’re often explaining these sorts of things [about blockers and hormones] to people who haven’t even had biology in high school yet … it’s always a good theory that you talk about fertility preservation with a 14-year-old, but I know I’m talking to a blank wall.”

Justice Thomas commented that state governments would have “good reason to question whether WPATH has a basis for believing that children can provide informed consent to sex-transition treatments.

“The voices of ‘detransitioners’—individuals who have undergone sex-transition treatments but no longer view themselves as transgender—provide states with an additional reason to question whether children are providing informed consent,” he said.

He recounted that, before enacting its statute, Tennessee’s legislature had heard from a detransitioner who explained she was not “capable of making informed lifelong decisions” as a teenager, and yet was allowed to undergo medical transition.

As for the claim by the Biden administration that detransitioners make up “a very small number” of those who go down the medical pathway, Justice Thomas cited evidence that the true rate of detransition is unclear in the era of rapidly growing gender clinic caseloads and less cautious treatment practices.

He noted the opinion that “those who abandon a transition are likely to stop talking to their doctors, and so disappear from the figures [tracking regret].”

Consistent with this view, the judge cited the result of a 2021 study by researcher Dr Lisa Littman that 76 in a group of 100 detransitioners did not take the step to tell their former clinicians that they had stopped hormones and re-embraced their biological sex.

“[Justice] Sotomayor’s dissenting opinion in US v Skrmetti is so rambling and incoherent. She was fed activist talking points and parrots them unthinkingly. It contrasts sharply with the majority and concurring opinions.”—Commentator Colin Wright, X/Twitter, 18 June 2025

‘Always felt he was a boy’

In her dissenting opinion, Justice Sonia Sotomayor said: “Tennessee’s law expressly classifies on the basis of sex and transgender status, so the Constitution and settled precedent require the court to subject it to intermediate scrutiny.

“Thus, the majority subjects a law that plainly discriminates on the basis of sex to mere rational-basis review. By retreating from meaningful judicial review exactly where it matters most, the court abandons transgender children and their families to political whims.

“In sadness, I dissent.”

She referenced the case of one of the plaintiffs.

“Ryan Roe, now 16, felt as early as elementary school that he ‘was a boy’,” Justice Sotomayor said.

“Before puberty, Ryan thought ‘there wasn’t that much of a difference between boys and girls and that he ‘could manage existing in the middle’.

“As puberty approached, however, Ryan grew increasingly anxious about the impending changes to his body. He started throwing up every morning before school. As his voice changed, Ryan contemplated going mute.

“Eventually, after two years of psychotherapy and extensive consultations with his parents and doctors, Ryan’s physicians prescribed him testosterone.

“Ryan began to find his voice again. He started raising his hand in class, participating in school, and looking at himself in the mirror. Ryan attests that ‘[g]ender-affirming health care saved [his] life’.”

1. In her analysis, lawyer Glenna Goldis says the court has not closed off all lines of attack on state bans. She writes: “This decision doesn’t vaporize all the litigation over [paediatric gender medicine] bans. Most (all?) of the challenges include parental rights claims, which this decision doesn’t touch. (Those arguments will fail eventually.) Some of the lawsuits are proceeding under state constitutions, as in Montana. (They might prevail.) And [Chief Justice] Roberts left the door ajar for ‘invidious discrimination’ arguments.”

2. US media reports of Skrmetti characterise the ruling as a conservative-liberal split on the bench. The gender clinic issue has been caught up in polarised politics. Republican-run states have led with restrictions on paediatric medical transition, while Democratic states have sought to entrench “gender-affirming care”.

3. In a footnote, the court majority appeared to discourage the idea that its use of the term “transgender boy” reflects a belief in gender ideology. The footnote said: “We use ‘transgender boy’ to refer to an individual whose biological sex is female but who identifies as male, and ‘transgender girl’ to refer to an individual whose biological sex is male but who identifies as female.”

4. Gender clinicians have relied on the longer track record and regulatory approval of precocious puberty treatment to claim that hormone suppression of a normally timed puberty is neither unsafe nor very novel.

5. A “desister” is a person who ceases to identify as trans or gender-diverse and who re-embraces birth sex.

6. Tennessee’s prohibition on trans surgery for minors was not under challenge in these proceedings.