WASHINGTON (AP) — The Supreme Court on Wednesday upheld Tennessee's ban on gender-affirming care for transgender minors, a stunning setback to transgender rights.

The justices' 6-3 decision in a case from Tennessee effectively protects from legal challenges many efforts by President Donald Trump's Republican administration and state governments to roll back protections for transgender people. Another 26 states have laws similar to Tennessee's.

Chief Justice John Roberts wrote for a conservative majority that the law does not violate the Constitution's equal protection clause, which requires the government to treat similarly situated people the same.

“This case carries with it the weight of fierce scientific and policy debates about the safety, efficacy, and propriety of medical treatments in an evolving field. The voices in these debates raise sincere concerns; the implications for all are profound,” Roberts wrote. “The Equal Protection Clause does not resolve these disagreements. Nor does it afford us license to decide them as we see best.”

In a dissent for the court's three liberal justices that she summarized aloud in the courtroom, Justice Sonia Sotomayor wrote, “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."

Efforts to regulate transgender people's lives

The decision comes amid other federal and state efforts to regulate the lives of transgender people, including which sports competitions they can join and which bathrooms they can use. In April, Trump’s administration sued Maine for not complying with the government’s push to ban transgender athletes in girls sports.

The Republican president also has sought to block federal spending on gender-affirming medical care for those under age 19 — instead promoting talk therapy only to treat young transgender people. And the Supreme Court has allowed him to kick transgender service members out of the military, even as court fights continue. The president signed another order to define the sexes as only male and female.

Trump's administration has also called for using only therapy, not broader health measures, to treat transgender youths.

Some providers have stopped treatment already

Several of the states where gender-affirming care has not been banned for minors have adopted laws or state executive orders seeking to protect it. But since Trump’s executive order calling for blocking federal funding for the treatment for those under 19, some providers have ceased some treatments. For instance, Penn Medicine in Philadelphia announced last month it would not provide surgeries for patients under 19.

The president of the American Academy of Pediatrics, Dr. Susan Kressly, said in a statement the organization is “unwavering” in its support of gender-affirming care and “stands with pediatricians and families making health care decisions together and free from political interference.”

Five years ago, the Supreme Court ruled transgender, gay and lesbian people are protected by a landmark federal civil rights law that prohibits sex discrimination in the workplace. That decision is unaffected by Wednesday’s ruling.

But the justices Wednesday declined to apply the same sort of analysis the court used in 2020 when it found “sex plays an unmistakable role” in employers’ decisions to punish transgender people for traits and behavior they otherwise tolerate. Roberts joined that opinion written by Justice Neil Gorsuch, who was part of Wednesday's majority.

Justice Amy Coney Barrett also fully joined the majority but wrote separately to emphasize that laws classifying people based on transgender status should not receive any special review by courts. Barrett, also writing for justice Clarence Thomas, wrote that “courts must give legislatures flexibility to make policy in this area.”

‘A devastating loss' or a 'Landmark VICTORY’

Chase Strangio, the American Civil Liberties Union lawyer who argued the case for transgender minors and their families, said in a statement that the ruling "is a devastating loss for transgender people, our families, and everyone who cares about the Constitution.”

Mo Jenkins, a 26-year-old trans woman who began taking hormone therapy at 16, said she was disheartened but not surprised by the ruling. “My transition was out of survival,” said Jenkins, a Texas native and legislative staffer at the state capitol in Austin.

Texas outlawed puberty blockers and hormone treatment for minors in 2023. The legislature in May also passed a bill that tightly defines a man and a woman by their sex characteristics.

“Trans people are not going to disappear,” Jenkins said.

Tennessee Attorney General Jonathan Skrmetti on social media called the ruling a “Landmark VICTORY for Tennessee at SCOTUS in defense of America’s children!”

There are about 300,000 people between the ages of 13 and 17 and 1.3 million adults who identify as transgender in the United States, according to the Williams Institute, at think tank at the UCLA School of Law that researches sexual orientation and gender identity demographics.

When the case was argued in December, then-President Joe Biden's Democratic administration and families of transgender adolescents called on the high court to strike down the Tennessee ban as unlawful sex discrimination and protect the constitutional rights of vulnerable Americans.

They argued the law violates the equal protection clause of the 14th Amendment.

Tennessee’s law bans puberty blockers and hormone treatments for transgender minors but allows the same drugs to be used for other purposes.

Soon after Trump took office, the Justice Department told the court its position had changed.

A major issue in the case was the appropriate level of scrutiny courts should apply to such laws.

The lowest level is known as rational basis review, and almost every law looked at that way is upheld. Indeed, the federal appeals court in Cincinnati that allowed the Tennessee law to be enforced held that lawmakers acted rationally to regulate medical procedures.

The appeals court reversed a trial court that employed a higher level of review, heightened scrutiny, which applies in cases of sex discrimination. Under this more searching examination, the state must identify an important objective and show the law helps accomplish it.

Roberts' 24-page majority opinion was devoted almost entirely to explaining why the Tennessee law, called SB1, should be evaluated under the lower standard of review. The law's restrictions on treating minors for gender dysphoria turn on age and medical use, not sex, Roberts wrote.

Doctors may prescribe puberty blockers and hormone therapy to minors of any sex to treat some disorders, but not those relating to transgender status, he wrote.

But in her courtroom statement, Sotomayor asserted that similar arguments were made to defend the Virginia law prohibiting interracial marriage that the Supreme Court struck down in 1967.

“A ban on interracial marriage could be described in the same way as the majority described SB1,” she said.

Roberts rejected the comparison.

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Associated Press writers Geoff Mulvihill, in Cherry Hill, N.J., and Nadia Lathan in Austin, Texas, contributed to this report.

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