The U.S. Supreme Court (SCOTUS) threw out judicial decisions that favored transgender people in cases from North Carolina, West Virginia, Idaho and Oklahoma, including in legal challenges to state health insurance programs that deny coverage for patients seeking gender-affirming medical treatment.

Acting in appeals by officials in North Carolina and West Virginia, the justices ordered lower courts to reconsider their decisions siding with the challengers to the insurance policies in light of the Supreme Court's major June 18 ruling that upheld a Republican-backed ban in Tennessee on treatments such as puberty blockers and hormones for minors experiencing gender dysphoria.

On June 27, SCOTUS ruled in favor of parents in Maryland who wanted to opt their children out of reading LGBTQ-themed books in schools, stating that this decision supports their First Amendment rights to religious expression. This 6-3 decision highlights the ongoing legal debates surrounding LGBQ and transgender content in education and parental rights.

The Supreme Court ruled that Tennessee's ban on youth transgender care wasn't in violation the U.S. Constitution's 14th Amendment promise of equal protection, as challengers to the law had argued. The court's conservative justices were in the majority and liberal justices in dissent in the 6-3 decision.

Gender dysphoria is the controversial diagnosis for the significant distress that can result from an incongruence between a person's gender identity and the sex assigned at birth.

The case from North Carolina involved the state employee health plan, which excludes medical and surgical treatment "leading to or in connection with sex changes or modifications and related care." In West Virginia, Medicaid - the state-federal health insurance program covering low-income Americans - has denied coverage for "transsexual surgery" since 2004. Medicaid is managed primarily by state governments. Twenty-three states and D.C. specifically include coverage for gender-affirming care under their Medicaid programs.

The Supreme Court routinely orders lower courts to revisit certain cases that were on appeal in order to apply new case standards and legal interpretations from the nation's top judicial body.

In a similar case, the Supreme Court ordered reconsideration of a lower court's ruling that allowed a lawsuit to proceed against an Idaho official accused of denying surgical care to transgender Medicaid beneficiaries in that state, also taking into account the June 18 ruling.

The justices also ordered reconsideration in a lower court's decision that revived a lawsuit challenging Oklahoma's policy barring transgender people from changing their birth certificates to match their gender identity. As in the Tennessee dispute, the plaintiffs had asserted that the policies violate the 14th Amendment and other laws.

The justices did not immediately act in three other pending appeals involving state laws in West Virginia, Idaho and Arizona that would ban transgender athletes from female sports teams at public schools. July 3 is the next day when the Supreme Court acts on whether or not to take up pending appeals.

The issue of transgender rights is a flashpoint in the U.S. culture wars. President Donald Trump during his 2024 election campaign promised to impose restrictions on gender-affirming care and sports participation, and since returning to office in January has taken aim at transgender rights.

The Supreme Court in May permitted Trump's administration to implement his ban on transgender people in the U.S. military.

Trump also has signed an executive order targeting what he called "gender ideology" and declaring that the federal government would recognize only two sexes: male and female. Trump also rescinded orders by his predecessor, Democrat Joe Biden, combating discrimination against gay and transgender people.

The Supreme Court's ruling in the Tennessee case could bolster efforts by states to defend other measures targeting transgender people.

Tennessee's law, passed in 2023, aimed to encourage minors to "appreciate their sex" by prohibiting healthcare workers from prescribing puberty blockers and hormones to help them live as "a purported identity inconsistent with the minor's sex."

The Supreme Court's ruling, written by Chief Justice John Roberts, highlighted the "ongoing debate among medical experts regarding the risks and benefits associated with administering puberty blockers and hormones," and found that the state law directly responds to that uncertainty.

The ruling, however, provides some room for future legal challenges and for lower courts to apply tougher legal scrutiny and potentially find unlawful discrimination involving other curbs on transgender rights.

The Supreme Court's recent rulings on transgender rights have often been influenced by ideological divides, with the conservative majority upholding state laws that restrict transgender health care for minors. Chief Justice Roberts' opinions have been criticized for lacking coherence and relying on outdated precedents, while dissenting justices argue that these decisions abandon protections for transgender individuals.

Case Information

U.S. v. Skrmetti

In 2023, Tennessee enacted Senate Bill 1 (SB1), which prohibits healthcare providers from prescribing or providing puberty blockers or hormones to minors for the purpose of enabling them to identify with a gender different from their biological sex or to treat discomfort from such discordance. However, SB1 allows these treatments for minors with congenital defects, precocious puberty, disease, or physical injury. Three transgender minors, their parents, and a doctor challenged SB1 under the Equal Protection Clause of the Fourteenth Amendment. SCOTUS vacated this decision. Supreme Court justices ruled to uphold a Tennessee law banning gender-affirming care for minors.

Mahmoud v. Taylor 

Mahmoud v. Taylor is a recent Supreme Court case where the court ruled that parents in Maryland can opt their children out of school lessons that include LGBTQ-themed storybooks, citing the First Amendment's protection of religious freedom. The decision allows parents to exclude their children from instruction that conflicts with their religious beliefs.

Kadel v. Folwell and Fain v. Crouch / Anderson v. Crouch

Richmond-based federal appeals court ruled that North Carolina and West Virginia had violated the 14th Amendment’s equal protection clause by excluding gender-affirming care from their insurance plans. SCOTUS vacated the Fourth Circuit's decision in these cases.

M.H. v. Jeppesen

The lawsuit was initially filed by two transgender individuals on Medicaid who were denied coverage for gender confirmation surgeries. They are represented by Idaho Legal Aid Services. The Idaho Department of Health and Welfare and its officials are named as defendants. The lawsuit argues that the denial of coverage violates the Equal Protection Clause, the Due Process Clause, and the requirements of the Medicaid Act.

Other Similar Cases

Poe v. Labrador

This suit challenges Idaho's ban on gender-affirming care for minors, but that case focuses on minors receiving gender-affirming care rather than Medicaid funding.

Vasquez v. Iowa Department of Human Services

The suit challenges an Iowa law that restored a ban on Medicaid coverage for essential gender-affirming surgery, which the Iowa Supreme Court had previously struck down.

Toomey v. State of Arizona

Is a class action lawsuit filed by the ACLU against Arizona for denying medically necessary gender-affirming healthcare to transgender people employed by the state or enrolled in the state health plan.

Outfront v. Johnson Piper 

ACLU lawyers filed a lawsuit in Minnesota challenging the state's ban on Medicaid coverage for transition-related surgery for transgender individuals.

Thomas et al v. Georgia Department of Community Health et al.

Two transgender women enrolled in Georgia Medicaid have sued the state, alleging that denying access to gender-affirming surgeries under Medicaid violates the U.S. Constitution, the Affordable Care Act, and the Medicaid Act. This case challenges the state's denial of coverage for medically necessary gender-affirming surgical care for Medicaid beneficiaries.

West Virginia v. B.P.J.

West Virginia filed with the Supreme Court requesting the high court hear its case State of West Virginia v. B.P.J., which had banned biological boys from competing in girls' sports. 

States that provide gender reassignment through Medicaid

The 23 states identified as having affirmative coverage policies are:

1. Alaska

2. California

3. Colorado

4. Connecticut

5. Delaware

6. Illinois

7. Maine

8. Maryland

9. Massachusetts

10. Michigan

11. Minnesota

12. Montana

13. Nevada

14. New Hampshire

15. New Jersey

16. New York

17. North Dakota

18. Oregon

19. Pennsylvania

20. Rhode Island

21. Vermont

22. Washington

23. Wisconsin