Supreme Court Ruling on Gender-Affirming Care Sparks Nationwide Health Care Debate

On June 18, 2025, the U.S. Supreme Court issued a landmark decision in United States v. Skrmetti, allowing Tennessee’s ban on gender-affirming care for minors to take effect. This ruling marks a significant shift in the legal landscape surrounding transgender issues, presenting urgent operational, compliance, and legal challenges for health care providers across the nation.

The Supreme Court, in a 6-3 decision, overturned the Sixth Circuit’s injunction that had previously blocked the enforcement of Tennessee’s law. This legislation prohibits health care providers in Tennessee from administering puberty blockers, hormone therapy, or gender-affirming surgeries to anyone under 18. Justice Gorsuch, writing for the majority, highlighted the state’s interest in regulating what he termed “experimental treatments,” framing the decision as a return to judicial restraint.

“The Constitution does not prohibit Tennessee from regulating medical interventions it deems harmful to children,”

he stated. In contrast, Justice Sotomayor’s dissent described the law as “a stunning intrusion into the medical judgment of families and their providers,” emphasizing that it unfairly targets transgender youth.

Implications for Health Care Providers Nationwide

This decision extends beyond political or cultural implications, emerging as a regulatory event with significant consequences for health care providers offering gender-affirming care throughout the country.

State Law Takes Precedence

The ruling effectively paves the way for states to regulate gender-affirming care independently. Health care providers must now navigate a complex and rapidly evolving patchwork of state laws. Currently, over 20 states have enacted bans or restrictions similar to Tennessee’s, while approximately 17 states have adopted “shield laws” to protect access to gender-affirming care.

This decision may prompt further state legislation, altering obligations for providers who serve transgender youth. Changes could include mandatory reporting requirements, restrictions on telehealth prescribing across state lines, limitations on parental consent procedures, or new civil and criminal penalties for facilitating out-of-state care. Similar to the abortion landscape, disparities in state support for gender-affirming care may lead patients to seek services in states without such restrictions.

Heightened Enforcement Risks

In states with existing bans on gender-affirming care, enforcement is no longer a theoretical concern. Tennessee’s prohibition allows the state medical board to discipline providers who violate the law, with similar penalties existing under other state statutes. The Skrmetti decision may embolden state attorneys general and medical boards to investigate or sanction providers perceived as offering gender-affirming care to minors, even inadvertently.

These risks must be weighed alongside potential enforcement of federal laws. Following directives from the White House, the U.S. Attorney General recently instructed Justice Department employees to investigate medical providers and pharmaceutical companies accused of misleading the public about the side effects of gender-affirming care for minors or allegedly violating federal laws such as the Female Genital Mutilation Act.

Increased Litigation Likely

Experts anticipate a surge in litigation as plaintiffs seek continued access to gender-affirming care, challenging state restrictions. Lawsuits asserting violations of equal protection, due process, discrimination based on disability, or federal preemption will persist. However, with the Court signaling deference to states, these challenges may face steeper odds.

Enforcement actions against providers of gender-affirming care are also expected to generate litigation as state and federal laws are interpreted. For instance, the federal Female Genital Mutilation Act, cited by the Attorney General, does not apply to surgical operations necessary for the patient’s health and performed by a licensed medical practitioner. Courts may need to address the scope of such exclusions intended to protect medical providers.

Federal Programs and Non-Discrimination Laws

Although the Court’s decision did not directly address Section 1557 of the Affordable Care Act (ACA), it could influence how courts interpret federal nondiscrimination requirements in health care. Section 1557 prohibits discrimination based on race, color, national origin, sex, age, or disability in certain health programs and activities.

Health care providers participating in Medicare, Medicaid, or other federally funded programs must carefully reconcile federal obligations with any conflicting state law restrictions.

Potential for a Federal Ban

The Skrmetti decision arrives as the federal government expresses its intent to prevent institutions receiving federal funding from providing or facilitating sex-reassignment procedures for minors. Although implementation of the Executive Order has been partially enjoined by courts, the Trump Administration has taken steps to discourage providers from furnishing gender-affirming care for minors, including an HHS report criticizing such treatments.

The Court’s decision will likely influence ongoing litigation challenging federal Executive Orders related to gender-affirming care, potentially weakening arguments that federal regulations protecting access to such care for minors violate the Constitution. However, other grounds for challenging the implementation of these Executive Orders remain.

Next Steps for Providers

The Skrmetti ruling is poised to accelerate legal changes affecting providers of gender-affirming care. Balancing patient needs, legal compliance, and professional ethics remains highly complex. Providers should:

• Work with legal counsel to assess liability exposure under both state and federal frameworks.
• Engage leadership to establish clear clinical and operational parameters related to offering gender-affirming care.
• Review and update operational practices to align with legal and business requirements, especially in telehealth or cross-border contexts.
• Reassess consent procedures to ensure they reflect current legal standards and adequately document patient protections.

As the legal landscape continues to evolve, health care providers must remain vigilant and adaptable, ensuring their practices comply with both state and federal regulations while meeting the needs of their patients.

About The Author