Gender-affirming care guidelines bring complex issues

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In June 2025, the U.S. Supreme Court upheld Tennessee’s law banning certain gender-affirming medical treatments for minors in U.S. v. Skrmetti. The decision grants states significant discretion to regulate such treatments regardless of a medical provider’s determination that such a course of action is medically appropriate.

Tennessee SB1

In 2023, Tennessee passed SB1, which prohibits the use of puberty blockers or hormone therapy for transgender teens. Supporters of the legislation argued that the law protected children from “irreversible medical procedures.”

Several transgender teenagers, their families, and a medical provider filed a lawsuit, alleging that the law constituted sex-based discrimination and violated the U.S. Constitution’s 14th Amendment right to equal protection. Originally, these parties were joined by the Biden Administration, though the Trump Administration reversed course saying that it did not believe the law needed to be challenged.

Level of scrutiny

At issue before the Supreme Court was the appropriate level of scrutiny to apply when considering the legality of SB1. The majority of the U.S. Supreme Court concluded that a more relaxed standard of review should be applied. This relaxed standard is known as the rational basis test, and means that Tennessee merely needed to demonstrate that there is a plausible reason for the law to uphold it.

The alternative, higher standard typically applies when a law seeks to treat people differently based on sex. In that case, states may only draw classifications if such categories serve “important governmental objectives” and the classification is “substantially related to the achievement of those objectives.”

The Supreme Court’s majority believed that no such classification occurred in SB1 because the ban applied to all minors who might receive care, regardless of their sex, an interpretation the liberal minority vehemently argued ignored the explicit language of the law referencing a state interest in encouraging minors “to appreciate their sex, particularly as they undergo puberty.”

Impact

While future legal battles remain, the decision has broad ramifications for the treatment of transgender patients across the country. Over half the states now have laws limiting gender affirming care for minors, and many of these laws include penalties for providers who defy the ban.

Locally, Maryland does not ban gender affirming care for minors, and Maryland’s Trans Shield Act protects both patients and providers from out-of-state prosecution and investigation. As a result, Maryland providers may see an influx of patients traveling to Maryland for care from states with restrictive laws such as Tennessee’s SB1.

Federal pressure

In December of 2025, the Centers for Medicare and Medicaid Services issued two proposed rules that, if implemented, would further restrict gender-affirming care.

The first proposed rule would prohibit hospitals enrolled in Medicare from treating gender dysphoria in minors with common treatments such as puberty blockers, hormone therapy, and surgical procedures. Providers that fail to adhere to the Condition of Participation risk being terminated from receiving Medicare payments for all services, and there are few, if any, hospitals that could survive without that funding.

The second proposed rule prohibits Medicaid funds administered by states from being used for gender affirming care for minors. States would have to rely exclusively on state funding to continue to provide these services.

If either rule is finalized, legal challenges will be immediate. The rules create conflicts with state laws that protect gender affirming care, as well as with other federal discrimination laws. These rules also interfere with an individual provider’s practice of medicine, substituting federal rulemaking for that which the provider believes is best or necessary care.

The proposed rules have already had a chilling effect. In January of 2026, some hospitals, such as Rady Children’s Hospital in San Diego and Children’s Hospital Colorado, announced plans to end gender-affirming medical care for patients under 18, citing the proposed rules as the basis for their decision. Other hospitals, under pressure from federal investigations, which have included attempts to subpoena medical records, have also announced the end of this type of care.

Barry F. Rosen leads the Health Care Practice Group at Gordon Feinblatt LLC, and he can be reached at 410-576-4224 or [email protected]. Alexandria K. Montanio is an associate in the Health Care Practice Group at Gordon Feinblatt LLC, and she can be reached at 410-576-4278 or [email protected].