By Devan Cole and John Fritze

(CNN) — The Supreme Court on Wednesday upheld Tennessee’s ban on gender-affirming care for trans minors in a blockbuster ruling that will bolster efforts by conservative state lawmakers to pass and preserve other divisive laws targeting transgender Americans.

The 6-3 decision by a conservative majority is a major blow to the transgender community and its advocates at a critical time. Since 2020, Republican-led states around the country have passed a wave of laws regulating the lives of trans Americans, with a particular focus on minors. And President Donald Trump, who ran for reelection in part on ending the “transgender lunacy,” has taken several steps intended to roll back gains made by that community.

Roughly half of the nation’s states have bans similar to Tennessee’s. Federal courts have disagreed on the constitutionality of those laws, and the Tennessee case, filed by the Biden administration, was the first to reach the high court.

The court’s majority opinion was penned by Chief Justice John Roberts and joined by the other five members of the conservative wing. The three liberals dissented.

“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,” Roberts wrote. “The voices in these debates raise sincere concerns; the implications for all are profound. The Equal Protection Clause does not resolve these disagreements.”

Moving forward, under the court’s ruling, judges examining bans like Tennessee’s – and, potentially, other restrictive laws – will do so under the lowest standard of judicial review, meaning those other laws are more likely to be upheld by courts.

The court “abandons transgender children and their families to political whims,” Justice Sonia Sotomayor, a member of the court’s liberal wing, wrote in dissent, taking the rare step of reading from the bench. “In sadness, I dissent.”

The liberal wing argued that the court’s conservative majority had tied itself in knots trying to avoid earlier precedents that said laws affecting transgender Americans necessarily discriminated on the basis of sex.

“The majority refuses to call a spade a spade,” Sotomayor wrote. “Instead, it obfuscates a sex classification that is plain on the face of this statute, all to avoid the mere possibility that a different court could strike down SB1, or categorical healthcare bans like it.”

Sotomayor wrote that the court’s opinion does “irrevocable damage to the Equal Protection Clause and invites legislatures to engage in discrimination by hiding blatant sex classifications in plain sight.”

Tennessee Attorney General Jonathan Skrmetti, a Republican who argued the case at the court, described the outcome as a “common sense” win over “judicial activism.”

“This victory transcends politics,” he said. “It’s about real Tennessee kids facing real struggles. Families across our state and our nation deserve solutions based on science, not ideology.”

Groups advocating for transgender Americans decried the decision.

Chase Strangio, a lawyer with the American Civil Liberties Union who represents the minors challenging Tennessee’s law and who also argued in court, said in a statement that the ruling “is a devastating loss for transgender people, our families, and everyone who cares about the Constitution.”

Politics hovers over decision

The politics of the issue shifted while the case was pending on the Supreme Court’s docket. Since returning to power in January, Trump has attempted to remove transgender Americans from the military – the justices in early May allowed that policy to take effect – and the president signed an executive order barring nonbinary markers on US passports. Some polling has suggested softening support for transgender gains among Democrats, including on the issue of transgender girls playing on girls sports teams.

Tennessee’s SB 1 bans hormone therapy and puberty blockers for transgender minors in the state and imposes civil penalties for doctors who violate the prohibitions. It also bans gender-affirming surgeries, though that provision was not at issue in the case. The law took effect in 2023.

Specifically, the law prohibits providers from administering such care if the purpose is to enable “a minor to identify with, or live as, a purported identity inconsistent with the minor’s sex,” or treat “purported discomfort or distress from a discordance between the minor’s sex and asserted identity.”

SB 1 was initially challenged by three trans minors in Tennessee, their parents and a doctor in the state whose practice included treating minors for gender dysphoria. The Biden administration later joined that lawsuit, and lower federal courts came to differing conclusions as to the law’s constitutionality.

The case landed at the court weeks after Trump was reelected following an election cycle in which he amplified a pledge to further curtail civil rights for trans people during the closing days of his campaign. Shortly after taking office, Trump’s Justice Department told the high court that it was no longer backing the challengers to the Tennessee law, reversing the Biden Justice Department’s position in the case.

A slew of other GOP-led states have passed similar health care bans in recent years. Today, more than 110,000 teenagers live in states where restrictions on puberty blockers and hormone therapy exist, according to the Williams Institute at UCLA School of Law.

A divided court of appeals in Cincinnati in 2023 allowed the ban to take effect.

In the courtroom

Inside the courtroom, Roberts read excerpts of his opinion for seven minutes. The chief spoke in his usual flat, steady manner, with a tone that suggested things were straightforward: this isn’t a classification based on sex, he said, adding that the law drew lines based on age and medical use. He referred to medical studies, highlighting various risks with the treatments, and closed with an admonition that the question was a matter for lawmakers to hash out.

Sotomayor, reading her dissent, spoke for more than twice as long. She spoke emphatically and with urgency about the potential costs to trans youth and of the majority abandoning the crucial role of judicial review.

She repeated the line from her opinion that she was dissenting in “sadness.”

One of the key questions for the high court was whether the law discriminated based on sex – a finding that would trigger a tougher review by courts under the 14th Amendment. The Biden administration noted that a child born as a girl would be entitled to puberty blockers and estrogen under the state’s law for certain medical conditions, but a child born as a boy would not be entitled to those treatments to live as a female.

“That is sex discrimination,” the Biden administration told the Supreme Court.

The argument rested in part on a blockbuster decision in 2020 called Bostock v. Clayton County, which found that federal law prohibits workplace discrimination on the basis of sex “necessarily” also covers gay and transgender workers. That 6-3 decision divided conservatives on the court.

Tennessee countered its law was based on age, not sex, and prohibits the use of the drugs for the specific purpose of facilitating a gender transition. The state argued it had a compelling interest in “encouraging minors to appreciate their sex” and argued it is empowered to make decisions regulating medical treatments. That was an argument that appeared to find a receptive audience when the case was argued in December.

CNN Chief Supreme Court Analyst Joan Biskupic contributed to this report.

This story has been updated with additional details.

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