On June 24, the Supreme Court issued its decision in the highly polarized case of United States v. Skrmetti. The opinion upheld Tennessee’s legislative denial of two types of medical care for gender dysphoria in young people: puberty blocking drugs and hormone administration. Twenty-seven states have passed similar legislation. Following the decision, several health insurers have amended their policies and will cease providing gender-affirming care for patients under the age of 19 who have not already begun treatment, regardless of whether such care is allowed by state law.
In response, a Facebook post by groups supportive of care posted: “trans youth are being denied life-saving care not because the science has changed, but because the political climate has.”
The second part of the statement is undoubtedly true. The first is subject to dispute. Sometimes science does not have a ready answer, or the evidence is insufficient to allow a scientific decision. In short, science has limits.
After reviewing thousands of data points, mainstream medical organizations in the UK and several European countries determined that transcare has not yet been proven safe. In the US, most mainstream medical organizations take the opposite view, although some agree with their British peers and even criticize the criticism of the UK report.
“Scientifically,” both sides can’t be correct, but it will take time (and data) to puzzle out the answer. For now, there are two approaches: let the doctor with medical expertise treat the child according to the prevailing standard of care (which differs across the oceanic divide), or recognize that for now, only religious and moral dictates can provide direction, and unabashedly admit that this must be the prevailing paradigm until science produces reliable data. [1]
Junk science begins when science is stretched beyond its limits. One illegitimate application of science was illustrated when both Skrmetti’s litigants and judges on both sides of the ideological spectrum perverted, permuted, and manipulated existing scientific knowledge to suit their desired ends. For example, the “liberal” side contended that because hormones are administered to natal boys suffering gynecomastia (enlarged breasts), there is no reason to deny this treatment to trans boys as an “off-label” use. The claim is disingenuous, as the standard of care, even for cis-boys, is to delay use of the drug as long as possible, rarely before age 16, and usually older than 18.
The argument against using puberty blockers raised by the conservative set is even more scientifically egregious.
The Skrmetti Case in Brief
At the risk of over-simplification, in a nutshell, the plaintiffs claimed that equal protection laws barred bans on trans-care as illegal sex discrimination. To sidestep the argument that states must treat individuals in similar situations alike, the Court created a linguistic sleight-of-hand, ruling that the case did not involve sex discrimination because the treatments under scrutiny affect trans boys and girls alike.
To justify judicial intervention in these cases, a rational relationship must exist between the legislation and a legitimate government purpose. Here, the Court tepidly relies on “protecting the health of minors” to justify that requirement. Recognizing that there is controversy within the medical community regarding trans-care, the Court head-scratchingly concludes this discord is ample predicate to let the legislators decide.
To weasel out of the “equal protection” conundrum, the Court depicts the treatments not as sex-related but as condition-dependent, meaning the differences between treating cis and trans children are not because of sex, but rather because of the different medical conditions presented.
Puberty Blockers: Disease or Condition Dependent?
Generally, drugs are prescribed to address biological conditions, called “diseases.” Over time, disease names can be changed, sometimes reflecting a better understanding of their causes, and sometimes to respect the heightened sensitivities of various populations. Nevertheless, labeling a drug as treating a “disease” is a practice born of convenience. Rather, it is the cause (manifesting by signs and symptoms) that dictates treatment (here, the choice of drug), not per se the “name” of the disease. Justice Roberts agrees:
“The plaintiffs and the dissent, however, contort the meaning of the term “medical treatment. … Notably absent from their framing is a key aspect of any medical treatment: the underlying medical concern the treatment is intended to address…”
Justice Roberts, however, disregards his own wisdom, as both sides of the ideological divide pervert the science to suit their desired result. Illustrating their ideological agendas, the justices either rejected or embraced both puberty blockers and hormones, treating both modalities as a single conflated class (“trans-care”). Rather than assessing these modalities separately, they lump the baby with the bathwater, conflating the different effects, risks, and safety profiles of each type of treatment, whether applied to trans or cis children.
Puberty Blockers and Diagnostic Definition: A Drug by Any Other Name
Disingenuously, but necessary to support their artificial construct, the majority defines puberty blockers as treating different diseases in trans children (gender dysphoria) and cis children (precocious puberty). Examining the Majority’s arguments for puberty blockers discloses their perfidy.
Precocious puberty is a condition occurring “when children's bodies begin to change into adult bodies too soon,” with “too soon” requiring clinical judgment based on the child’s presentation, in comparison to their peers.
In actuality, the indications for puberty blockers are the same in cis or trans children: These drugs retard the manifestation of secondary sex characteristics, regardless of gender or sex. The same chemicals (GnRH agonists) are used for the same purpose in boys and girls, cis or trans, in the same way — to retard anatomical maturation and to address psychological concerns. Calling the disease in question either precocious puberty or gender dysphoria does not change the fact that in both cases the drug retards sexual expression — i.e., “blocks puberty.” The only real difference is the diagnostic code on the chart.
Safety, Off-label Use, and the Legislative Practice of Medicine
The Court then claims these drugs are used for trans youth “off label”, i.e., not for the purpose for which their safety was tested, arguing that this type of use, while entirely legal, subjects the users to heightened risk. However, the FDA-approved use was for delaying the manifestation of secondary sex characteristics in both sexes. So, in fact, the drug is being used for the very purpose for which it was approved. But even if this were not the case, all FDA-approved drugs must satisfy a basic level of safety established in Phase I of the Clinical trial. This process allows “off-label” usage, assuring a modicum of patient safety when the drugs are used for conditions not explicitly tested. In these cases, the physician assumes the role of weighing risks and benefits for the particular patient.
Further, puberty blockers present the same risk or safety hazards, e.g., bone density issues, in cis and trans children, and their effects are reversible (as opposed to those of hormones). This means the informed consent obstacle is the same for both cis and trans children.
The majority then claims, without support or citation, that trans youth are exposed to puberty blockers longer than cis children, as cis children stop taking the drug at the “normal” age of puberty, while no similar cut-off applies to trans children. While puberty blocker use may continue to a later age in trans children, in cis children, its use begins earlier, as early as age 6. Because no particular age cut-off is specified in the FDA approval package, typical use duration could be six or more years in both cis and trans children (where prescription begins later, and may last until puberty is complete). In real life, the duration of treatment may actually be longer in cis children than trans children.
I Define, Therefore I Win
In short, while the denial of puberty blockers to trans children may not be on the basis of sex, it’s not based on condition (which is the same in trans and cis children, male or female) either. Seemingly, the distinction is made based on some arbitrarily court-created class: having a diagnosis of “trans.”
After noting the medical community is in discord regarding how to treat trans children, rather than vesting the complex medical decision in the hands of those trained to address medical controversy (the child’s treating physician), the Court vests the decision in the hands of the legislature.
The irony is real. The Court refuses to allow physicians to prescribe puberty blocker drugs off-label because of safety concerns, entrusting this safety decision to the legislature. Yet, supposedly safety-conscious legislatures now allow pharmacists to dispense at least one drug, ivermectin, on patient request – as an over-the-counter (OTC) drug with even less FDA oversight than off-label drugs — without any doctor’s intervention at all. In some states, legislative fiat allows patients, even children, to take ivermectin for any reason they want, with no direction as to dosage, and without anyone doing a risk-benefit analysis.
So, it seems at the end of the day, who needs doctors? If we are going to let moral dictates govern, let’s be honest and up front about it. And ultimately, let’s ask: do we really want the legislature to make medical decisions?
[1] This will be challenging given the current administration’s opposition to collecting such information.
A shorter version was previously published on Harvard Bill of Health, July 21, 2025
