On June 24, 2024, the U.S. Supreme Court agreed to hear the case of U.S. v. Skrmetti where they will decide the hotly contested issue of transgender medical procedures for minors. This divisive topic is splitting the country along political lines with thirteen blue states from Massachusetts to California protecting transgender medical care for children, while sixteen red states from West Virginia to Utah ban such treatment. Four additional red states, including Texas and Montana, ban these procedures but their laws are currently being litigated. This flurry of legislation is not surprising given the nationwide surge in the number of transgender minors. Today, there are over 1.6 million transgender youth in the U.S., which is more than double the number of just seven years ago. With this rise, there is a corresponding increase in the number of medical treatments for transgender minors including puberty blockers, hormone therapy, and gender affirming surgery. Despite the controversy over these procedures, there is an unprecedented demand, with the number of gender affirming clinics rising from zero in 2009 to over one hundred today with long waiting lists. Moreover, the number of children taking puberty blocking hormones has doubled from 1,905 in 2017 to 4,321 in 2022, with a total of 14,726 during that five-year period. Opponents of these procedures argue they are still experimental with risks of infertility, depression, suicide, and irrevocable bone density loss. However, the American Medical Association and the American Academy of Child and Adolescent Psychiatry counter that these treatments provide important relief for youth suffering from gender dysphoria, a condition where a person identifies with a gender different than their biological sex at birth. As this debate intensifies, the Supreme Court prepares to hear arguments in the Skrmetti case this fall, with a decision expected in June.

         Surrounding the controversy over transgender medical care for minors is a significant backlash against the LGBTQ community with 604 anti-LGBTQ bills introduced in state legislatures in 2023, and more than 620 state bills restricting LGBTQ rights introduced as of July 2024. The LGBTQ community is fighting back, and on March 31, 2024, LGBTQ youths demonstrated in the Transgender Day of Visibility (TDV), one of the largest youth-led protests and classroom walkouts spanning all 50 states. President Biden’s administration expressed support for TDV in a White House Press Release declaring, “Today, we send a message to all transgender Americans: You are loved. You are heard. You are understood. You belong.”  In addition to TDV, LGBTQ youth started the Day of No Silence on April 12, 2024, marking a change from their 30-year annual silent protest. According to Melanie Willingham-Jaggers, executive director of the Gay, Lesbian, and Straight Education Network, the event encourages students to speak out against bigotry while “embracing a proactive stance.” Parents of transgender youth are also speaking out, including loud outbursts of “You’re killing my kid,” and “Blood on your hands,” as the North Carolina General Assembly voted to ban gender affirming surgery for teens on August 16, 2023. The anger of these parents reflects the high suicide rate for transgender youth with over 1.8 million LGBTQ minors in the U.S. seriously considering suicide every year, and at least one attempting suicide every 45 seconds. Other transgenders are coping by relocating to “trans-friendly” states, like Rylee Brock, a trans female who moved from Omaha, Nebraska to Champaign, Illinois, after the Nebraska Legislature banned transgender surgery for minors. As Brock explains, “It really made us feel not welcome. We looked at it and we’re like, okay, there’s a target on us. In Omaha, I couldn’t be myself, except in very safe spaces.”

       Despite the backlash against the LGBTQ community, those opposing transgender medical treatments for minors argue the procedures are unproven and unsafe with a myriad of side-effects including infertility, permanent bone density loss, depression, and sexual dysfunction.  For example, California teenager Chloe Cole claims she suffered irreparable harm after Kaiser “railroaded her” into gender reassignment treatment and surgery before she turned 18.  A self-described “detransitioner,” Cole is currently suing Kaiser after undergoing a double mastectomy and intensive hormone and puberty blocker treatment that left her with permanent health problems. According to Cole, she now suffers “deep physical and emotional wounds, severe regrets, and a distrust of the medical system.” Yet Cole is not alone, as other youth who underwent gender reassignment procedures immensely regret their decision like Lisa Powell who explains, “I was told there is one cure and one thing to do if this is your problem, and this will help you.”

      Outraged at outcomes such as Cole’s and Powell’s, some extreme critics have made death threats against transgender health care providers and created bomb scares at their clinics. For example, the Gender Multi-specialty Service Clinic at Boston Children’s Hospital is battling bomb threats, massive protests, and direct threats to individual clinic workers. Yet Boston Children’s Hospital is not alone as twenty-four U.S. hospitals and clinics providing transgender treatment for minors are also being targeted with bomb threats and death threats leading to suspending services. Meredith McNamara, a professor of pediatrics and adolescent medicine at Yale University, believes there is a chilling effect on these procedures due to the constant death threats, harassment, and fear of litigation. As McNamara explains, “I got an email telling me that I’m evil, I’m foolish, my work is opposing God, that I harm children, that I’m going to hell, and that I should die.”  Another threat against transgender medical providers is “doxxing,” where private or identifying information about them is published online with the intent that they be harmed. As a result of “doxxing,” these medical professionals are debating whether to buy guns as they scour the internet to see if their private information is published, while trying to remove their addresses from property records.

         Yet not all opponents of transgender medical procedures for minors are extremists. For example, Ohio representative Gary Click sponsors a ban on these procedures and explains, “I am totally against extremism. I think extremism begets extremism. I’m trying to be that level-headed person that comes in and says, ‘Listen, let’s look at the science.'” Click’s concern about these procedures is shared by the Biden Administration when it comes to surgery as a White House spokesperson declared, “these are deeply personal decisions, and we believe these surgeries should be limited to adults.” In addition to the White House, the U.S. Food and Drug Administration has not approved puberty blockers for transgender therapy and ordered a warning label about psychiatric problems after receiving several reports of suicidal thoughts. Moreover, no long-term studies have tracked child patients to determine how many are satisfied as adults and how many regret transitioning. Accordingly, the National Institute of Health reports,“the evidence is limited on whether these treatments pose short-term or long-term health risks for transgender and other gender-diverse adolescents.” As a result, families choosing these treatments for their children are venturing into uncertain territory, where science has not caught up with practice.

      As this contentious issue continues to divide the country, the Supreme Court will step and attempt to resolve the dispute in the above-noted Skrmetti case.  Skrmetti’s plaintiffs are three transgender minors who are challenging a 2023 Tennessee law banning transgender hormone treatments and surgeries for minors. The Skrmetti plaintiffs claim this law violates their equal protection and due process rights under the Constitution. In support of their claim, they rely on the 2020 case of Bostock v. Clayton County where the Court held, “it is impossible to discriminate against a person for being homosexual or transgender without discriminating against that individual based on sex.” The 6th Circuit Appellate Court disagreed with plaintiff’s argument, ruling that the Tennessee statute is “not discriminatory at all, as it regulates sex-transition treatments for all minors, regardless of sex.” As Judge Jeffrey Sutton explains, “Under the law, no minor may receive puberty blockers or hormones or surgery in order to transition from one sex to another. Such an across-the-board regulation lacks any of the hallmarks of sex discrimination.” As the Supreme Court prepares to hear the appeal of this case in the fall, the focus will be on Justices Amy Coney Barrett and Brett Kavanaugh, who are ideologically “in the middle” of the Court, and voted in April to reinstate Idaho’s ban on gender-affirming care for minors in Labrador v. Poe. On the other hand, right leaning Chief Justice John Roberts and Justice Neil Gorsuch were part of the majority’s decision in the noted Bostock decision. While the outcome is Skrmetti is uncertain, it has already made history as the first Supreme Court case dealing exclusively with transgender rights. In the interim, the country must await this highly anticipated ruling expected next year while the issue of transgender medical treatment for minors remains hotly contested and divisive.

Suggestions for Further Reading:

1. U.S. News and World Report: Supreme Court agrees to hear the case of U.S. v. Skrmetti and decide the fate of transgender medical care for youth.

2. Department of Health and Human Services (HHS) Office of Population Affairs: Categorizes and provides definitions of the different medical treatments and procedures available to transgender minors.

3. New York Times: Biden Administration opposes transgender surgery for minors.

4. UCLA School of Law Williams Institute: Demographic study of the transgender youth population.

5. The Trevor Project: 2024 U.S. National Survey on the mental health of transgender youth.

6. Association of American Medical Colleges: Informative discussion on gender affirming care for transgender people.

7. Associated Press News: Explains the significance and history of the Transgender Day of Visibility.

8. American College of Pediatricians: Discusses the risks of transgender medical treatments for children.

9. National Public Radio (NPR): Describes threats against health care providers of transgender youth.

10. Congressional Digest: Compares the pros and cons of transgender medical procedures for minors.