In a highly anticipated ruling, the U.S. Supreme Court, in a 6–3 decision, upheld Tennessee’s ban on medical interventions for the treatment of gender dysphoria in minors. In the United States v. Skrmetti, three trans-identified minors and their families challenged Tennessee’s ban under the Equal Protection Clause of the Fourteenth Amendment. Before reaching the Supreme Court, a District Court determined that the law likely discriminates on the basis of sex and transgender status and should be subject to “intermediate scrutiny,” which increases the burden on Tennessee to prove that its law is “substantially related” to an “important government interest.” The Sixth Circuit reversed that ruling, concluding that the law did not trigger heightened scrutiny and was instead subject to rational basis review. In the majority opinion written by Chief Justice John Roberts, the court echoed the Sixth Circuit’s reasoning finding that Tennessee’s law only draws distinctions based on age and clinical purpose rather than sex or transgender status and is therefore subject to rational basis review. Given the Tennessee legislature’s finding that gender-affirming medical interventions for minors are experimental and lack long-term evidence, the Court emphasized deference to state legislatures in matters of medical uncertainty. While the Supreme Court’s ruling in Skrmetti only directly affects Tennessee, it strongly signals that laws banning gender-transition procedures for minors are constitutionally permissible under rational basis review and are likely to be upheld in future legal challenges.
An insightful new piece in the New York Times Magazine tells the story of how the Transgender Rights Movement Bet on the Supreme Court and Lost. The article comprehensively chronicles the highs and lows of the transgender rights movement and describes how it bet a tremendous amount of political and cultural capital on the belief that “children have a constitutional right to treatments that halt and redirect their physical adolescence.” As the justifications for treating minors with medical interventions began to “unravel amid growing scrutiny by other doctors and experts,” some LGBTQ activists came to believe that taking Skrmetti to the Supreme Court was a massive strategic error and that the court was unlikely to “expand constitutional civil rights protections to a new class of Americans — let alone on the grounds of medical transition for minors.” The piece is worth reading in full for its detailed overview of the most significant developments in the political and cultural ascent of pediatric gender medicine.
A controversial new paper in the Journal of Sexual Medicine concluded that most trans-identified individuals treated with puberty suppression do not experience sexual dysfunction or dissatisfaction. The study also concluded that outcomes were similar for patients treated with early puberty suppression and late puberty suppression. The latter conclusion, in particular, clashes with statements made by former WPATH president and famed sex-reassignment surgeon, Marci Bowers. An analysis by the Society for Evidence-Based Gender Medicine (SEGM) also notes: the study suffers from small sample size and low participation rates, with only 48% of eligible participants taking part in the study. For trans-identified males, the participation rate was even lower at 30%. Indeed, the sample was so small for participants with early puberty suppression that no statistical analyses could be performed, meaning no conclusions can be made about the effects of earlier vs. later pubertal suppression on later sexual functioning. SEGM ultimately concludes that “the only conclusion that can be made with some degree of confidence is that puberty-suppressed individuals have high rates of sexual dysfunction in adulthood (at average age 29). About 30% have not been sexually active in a year. In addition, 50% of males (MtF) and 58% of females (FtM) reported having one or more sexual dysfunction.”
Earlier this week, U.S. District Judge Julia Kobick blocked enforcement of the Trump administration’s passport policy, which require passports to reflect one’s sex rather than one’s “gender identity.” Judge Kobick issued an injunction blocking enforcement of the policy earlier this year, but that injunction was limited in scope to only six plaintiffs. Tuesday’s ruling expands the injunction to “transgender or nonbinary people who are currently without a valid passport, those whose passport is expiring within a year, and those who need to apply for a passport because theirs was lost or stolen or because they need to change their name or sex designation.”
According to emails obtained by the Daily Caller, Title IX administrators and consultants around the country have discussed creative ways to circumvent the Trump administration’s Title IX policies, which define protections for women based exclusively on biological sex, not “gender identity.” One strategy considered framing gender ideology as a religious belief in order to claim that one’s gender expression and identity are extensions of that belief and subject to religious protections. “These latest emails highlight the outsized role that professional organizations have played in the gender debate, not only advocating in favor of expansive gender policies in schools but also in blocking reforms thereof. It is unconscionable that public employees drawing taxpayer-funded salaries are scheming on list serves how to circumvent the law” said Nicole Neily of Parents Defending Education and Speech First.
A new meta-analysis of twenty studies assessed the effects of testosterone therapy on the kidney functioning of trans-identified females over the course of 24 months, noting statistically significant changes in functioning which the authors attribute to physiological adaptations to testosterone rather than to true kidney dysfunction. The authors, however, are cautious in their interpretation. The authors used the glomerular filtration rate (eGFR) as a proxy for kidney function. They also looked at “secondary markers of kidney functions.” They noted a “decrease in eGFR at 6 and 12 months with respect to baseline, using the attributed (female) gender. When the CKD-EPI equation was referred to the perceived (male) gender, eGFR significantly decreased after 12 months but not after 6 months of T-GAHT.” The authors attribute the pattern to increases in muscle mass and creatinine production from testosterone, and note that other biomarkers assessing kidney function, like blood urea nitrogen (BUN), did not change after six or twelve months. “Further research is warranted to identify more accurate tools for evaluating kidney function in this population, particularly during the early months of treatment or in individuals with pre-existing renal conditions.”
Hannah Barnes sheds light on the UK’s pivot towards considering a ban on cross-sex hormones for dysphoric minors. According to Barnes, two expert reports characterizing the severe health risks posed by cross-sex hormones helped shift the government’s decision-making calculus. One report, written by the chief psychiatrist at one of the two government approved pediatric gender clinics in Finland, Dr. Riittakerttu Kaltiala, describes concerns about the physiological impact of cross-sex hormones coupled with her observations that the patient population seeking treatment today is more likely to experience regret “than what is suggested by older studies.” A second report by Swedish pediatric endocrinologist Dr. Jovanna Dahlgren also highlighted that “many years with daily treatment with cross sex hormones will increase the risk of cardiovascular disease… and stroke… [and] can decrease fertility, impair liver function and increase the risk of cancer in both genders.”
Joseph Figliolia
Policy Analyst
