Amicus Curiae Brief — United States, Petitioner v. Jonathan Skrmetti, Attorney General and Reporter for Tennessee, et al.

Supreme Court briefSep 3, 2024

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No. 23-477

IN THE

Supreme Court of the United States

_________

UNITED STATES OF AMERICA,

Petitioner,

JONATHAN SKRMETTI, ATTORNEY GENERAL AND

REPORTER FOR TENNESSEE, ET AL.,

Respondents.

________

On Writ of Certiorari to the

United States Court of Appeals for the Sixth Circuit

________

BRIEF OF THE AMERICAN PSYCHOLOGICAL

ASSOCIATION AND OTHER LEADING MENTAL

HEALTH ORGANIZATIONS AS AMICI CURIAE

IN SUPPORT OF PETITIONER

________

DEANNE M. OTTAVIANO

AMERICAN PSYCHOLOGICAL

ASSOCIATION

750 First Street NE

Washington, DC 20002

(202) 336-6100

HOWARD S. SUSKIN

JENNER & BLOCK LLP

353 North Clark Street

Chicago, IL 60654

(312) 222-9350

JESSICA RING AMUNSON

Counsel of Record

ILLYANA A. GREEN

JESSICA SAWADOGO

JENNER & BLOCK LLP

1099 New York Avenue NW

Suite 900

Washington, DC 20001

(202) 639-6000

jamunson@jenner.com

Counsel for Amici Curiae

TABLE OF CONTENTS

TABLE OF AUTHORITIES ...........................................ii

INTEREST OF AMICI CURIAE .................................. 1

SUMMARY OF ARGUMENT ......................................... 5

ARGUMENT ..................................................................... 10

I. Gender-Affirming Care Is the Accepted

Treatment Protocol for Treating Children

and Adolescents with Gender Dysphoria. ......... 10

II. Gender-Affirming Medical Care Is

Effective, Evidence-Based, and Safe. ................ 15

III. Banning Gender-Affirming Medical Care

Would Irreparably Harm the Mental

Health and Emotional Well-Being of

Transgender Youth. .............................................. 26

IV. Banning Gender-Affirming Medical Care

Disrupts the Role of Providers in Offering

Evidence-Based, Medically Accepted

Care. ........................................................................ 28

V. The Sixth Circuit Relied on Misleading

and Unfounded Narratives that Create a

Distorted Perception of the Psychological

and Medical Support Necessary for

Transgender Youth. .............................................. 31

CONCLUSION ................................................................. 34

TABLE OF AUTHORITIES

OTHER AUTHORITIES

Roberto L. Abreu et al., “I Am Afraid for

Those Kids Who Might Find Death

Preferable”: Parental Figures’ Reactions

and Coping Strategies to Bans on Gender

Affirming Care for Transgender and

Gender Diverse Youth, 9 Psych. Sex.

Orientation & Gender Diversity 500

(2020) .......................................................................... 18

Roberto L. Abreu et al., Impact of GenderAffirming Care Bans on Transgender

and Gender Diverse Youth: Parental

Figures’ Perspective, 36 J. Fam. Psych.

643 (2022) ............................................................. 26, 27

Christal Achille et al., Longitudinal Impact

Gender-Affirming

Endocrine

Intervention on the Mental Health and

Well-Being of Transgender Youths:

Preliminary Results, Int’l J. Pediatric

Endocrinology (2020) ............................................... 19

Luke R. Allen et al., Well-Being and

Suicidality Among Transgender Youth

After Gender-Affirming Hormones, 7

Clinical Prac. Pediatric Psych. 302 (Sept.

2019) ..................................................................... 17, 21

Anthony N. Almazan & Alex S.

Keuroghlian,

Association

Between

Gender-Affirming Surgeries and Mental

Health Outcomes, 156 JAMA Surgery

611 (2021) ................................................................... 20

iii

Am. Med. Ass’n, Comm. on Human

Sexuality, Human Sexuality (1972) ....................... 8

Am. Psych. Ass’n, APA Policy Statement

on Affirming Evidence-Based Inclusive

Care for Transgender, Gender Diverse,

and Nonbinary Individuals, Addressing

Misinformation, and the Role of

Psychological Practice and Science (Feb.

2024),

https://www.apa.org/about

/policy/transgender-nonbinary-inclusivecare.pdf ...................................................................... 16

Am. Psych. Ass’n, APA Resolution on

Gender Identity Change Efforts (2021),

https://www.apa.org/about/policy/resolut

ion-gender-identity-change-efforts.pdf ............ 6, 15

Am Psych. Ass’n, Ethical Principles of

Psychologists and Code of Conduct

(effective Jan. 1, 2017), https://www.apa.

org/ethics/code/ethics-code-2017.pdf ............... 29, 30

Am. Psych. Ass’n, Guidelines for

Psychological

Practice

with

Transgender

and

Gender

Nonconforming People, 70 Am. Psych.

832 (2015) ......................................................... 6, 16, 25

Am. Psych. Ass’n, Policy Statement on

Evidence-Based Practice in Psychology,

https://www.apa.org/practice/guidelines/

evidence-based-statement (last updated

Apr. 2021) .................................................................. 20

Am. Psych. Ass’n & Nat’l Ass’n of Sch.

Psychs., Resolution on Gender and

Sexual

Orientation

Diversity

Children and Adolescents in Schools

(2015), https://www.apa.org/about/policy/

orientation-diversity ......................................... 27, 28

Am. Psych. Ass’n, Report of the APA Task

Force on Gender Identity and Gender

Variance, 35 (2009), https://www.apa.org

/pi/lgbt/resources/policy/

gender-identity-report.pdf ............................... 11, 14

Am. Psych. Ass’n, Report of the American

Psychological Ass’n Task Force on

Appropriate Therapeutic Responses to

Sexual Orientation (2009), http://www.

apa.org/pi/lgbt/resources/therapeutic-re

sponse.pdf.................................................................... 6

Am. Psychiatric Ass’n, Diagnostic and

Statistical Manual of Mental Disorders:

DSM-5 – TR (2022) ................................................ 6, 7

Arkansas H.B. 1540 (2021) .......................................... 30

Florence Ashley et al., RandomizedControlled Trials are Methodologically

Inappropriate

Adolescent

Transgender Healthcare, 25 Int’l J.

Transgender Health 407 (2024).............................. 22

Jonathan T. Avila, Normal Adolescent

Growth

and

Development,

Encyclopedia of Child and Adolescent

Health: Biological Development and

Physical Health 735 (Bonnie HalpernFelsher ed. et al., 2023) ........................................... 13

Harry Barbee et al., Anti-Transgender

Legislation—A Public Health Concern

for Transgender Youth, 176 JAMA

Pediatrics 125 (2022) ................................................ 28

Greta R. Bauer et al., Intervenable Factors

Associated with Suicide Risk in

Transgender Persons: A Respondent

Driven Sampling Study in Ontario,

Canada, 15 BMC Pub. Health 525 (2015) ............. 21

Judith Bradford et al., Experiences of

Transgender-Related

Discrimination

and Implications for Health: Results

From the Virginia Transgender Health

Initiative Study, 103 Am. J. Pub. Health

1820 (2013), https://www.ncbi.nlm.nih.

gov/pmc/articles/PMC3780721/ .............................. 27

William Byne et al., Assessment and

Treatment of Gender Dysphoria and

Gender Variant Patients: A Primer for

Psychiatrists, 175 Am. J. Psychiatry 1046

(2018) .......................................................................... 11

Diane

Chen

al.,

Psychosocial

Functioning in Transgender Youth after

2 Years or Hormones, 388 New Eng. J.

Med. 240 (2023) ................................................... 17, 21

Beth A. Clark & Alice Virani, This Wasn’t a

Split-Second Decision: An Empirical

Ethical Analysis of Transgender Youth

Capacity, Rights, and Authority to

Consent to Hormone Therapy, 18 J.

Bioethical Inquiry 151 (2021) ................................. 31

Terryann C. Clark et al., The Health and

Well-Being of Transgender High School

Students: Results from the New Zealand

Adolescent Health Survey, 55 J.

Adolescent Health 93 (2014) ................................... 19

E. Coleman et al., World Professional

Association for Transgender Health

(“WPATH”), Standards of Care for the

Health of Transgender and Gender

Diverse People, Version 8, 23 Int’l J.

Transgender Health S1 (Sept. 2022),

https://www.tandfonline.com/doi/

pdf/10.1080/26895269.2022.

2100644 ............................ 11, 12, 13, 14, 15, 23, 25, 26

Rosalia Costa et al., Psychological Support,

Puberty Suppression, and Psychosocial

Functioning in Adolescents with Gender

Dysphoria, 12 J. Sex. Med. 2206 (2015) ................ 24

Claire A. Coyne et al., Gender Dysphoria:

Optimizing Healthcare for Transgender

and Gender Diverse Youth with a

Multidisciplinary

Approach,

Neuropsych. Disease & Treatment 479

(2023),

https://ncbi.nlm.nih.gov/pmc/

articles/PMC9985385/ .............................. 7, 13, 25, 33

vii

Lindsey Dawson et al., Youth Access to

Gender Affirming Care: The Federal and

State Policy Landscape, Kaiser Fam.

Found. (June 1, 2022) ............................................... 30

Annelou L.C. de Vries et al., Puberty

Suppression in Adolescents with Gender

Identity Disorder: A Prospective FollowUp Study, 8 J. Sex. Med. 2276 (2011) ........ 17–18, 22

Annelou L.C. de Vries et al., Young Adult

Psychological Outcome After Puberty

Suppression and Gender Reassignment,

134 Pediatrics 1 (2014) ............................................. 24

Lore M. Dickey et al., Univ. of Cal. S.F.,

Transgender Care, Mental Health

Considerations with Transgender and

Gender

Nonconforming

Clients,

https://transcare.ucsf.edu/guidelines/me

ntal-health ........................................................... 13–14

Mickey Emmanuel & Brooke R. Bokor,

Tanner Stages, StatPearls (last updated

Dec. 11, 2022), https://www.ncbi.nlm.nih.

gov/books/NBK470280/ ..................................... 12, 13

Anthony W.P. Flynn et al., When the

Political

Professional:

Civil

Disobedience in Psychology, 76 Am.

Psych. 1217 (2021) .................................................... 30

Gender Dysphoria, APA Dictionary of

Psychology (updated Nov. 15, 2023),

https://dictionary.apa.org/gender-dys

phoria ....................................................................... 7, 8

viii

GLAAD, Medical Association Statements

in Support of Health Care for

Transgender People and Youth (June 26,

2024), https://glaad.org/medical-associa

tion-statements-supporting-trans-youthhealthcare-and-against-discriminatory/ ........... 8, 16

Amy E. Green et al., Association of GenderAffirming Hormone Therapy With

Depression, Thoughts of Suicide, and

Attempted Suicide Among Transgender

and Nonbinary Youth, 70 J. Adolescent

Health 643 (2022) ............................................... 18–19

Mark Hatzenbuehler et al., Proposition 8

and Homophobic Bullying in California,

143 Pediatrics e20182116 (2019) ............................. 26

Wylie C. Hembree et al., Endocrine

Treatment of Gender-Dysphoric/GenderIncongruent Persons: An Endocrine

Society* Clinical Practice Guideline, 102

J. Clinical Endocrin. & Metabolism 3869

(2017) ............................................ 13, 14–15, 23, 24, 26

Natalie Holt et al., The OftenǦCircuitous

Path to Affirming Mental Health Care

for Transgender and GenderǦDiverse

Adults, 25 Current Psychiatry Reps. 105

(2023) .......................................................................... 31

Debra A. Hope & Jae A. Puckett, Bans on

Evidence-Based Care for Transgender

and Gender Diverse People Present

Risks for Clients and Dilemmas for

Mental Health Providers, 31 Cognitive &

Behav. Prac. 15 (2023) ............................................. 20

Landon D. Hughes et al., “These Laws Will

Be Devastating”: Provider Perspectives

on Legislation Banning GenderAffirming Care for Transgender

Adolescents, 69 J. Adolescent Health 976

(2021) .................................................................... 28–29

Jaclyn M. White Hughto et al., Transgender

Stigma and Health: A Critical Review of

Stigma Determinants, Mechanisms, and

Interventions, 147 Soc. Sci. Med. 222

(2015) .......................................................................... 27

Karine Khatchadourian et al., Clinical

Management of Youth with Gender

Dysphoria in Vancouver, 164 J.

Pediatrics 906 (2014) ................................................ 24

Kacie M. Kidd et al., “This Could Mean

Death

for

Child”:

Parent

Perspectives on Laws Banning GenderAffirming Care for Transgender

Adolescents, 68 J. Adolescent Health

1082 (2021) ................................................................. 18

Laura L. Kimberly et al., Ethical Issues in

Gender-Affirming Care for Youth, 142

Pediatrics e20181537 (2018) .................................... 20

Damian Krebs et al., Care for Transgender

Young People, 95 Hormone Rsch.

Paediatrics 405 (2022) .............................................. 29

Simone Mahfouda et al., Gender-Affirming

Hormones and Surgery in Transgender

Children and Adolescents, 7 Lancet

Diabetes Endocrin. 484 (2019) ............................... 20

Alexa Martin-Storey et al., Barriers to

Health Care and Mental Health Among

Parents of Transgender and Gender

Diverse Youth, Transgender Health (July

2024) ........................................................................... 18

Meredithe McNamara et al., An EvidenceBased Critique of “The Cass Review” on

Gender-affirming Care for Adolescent

Gender Dysphoria (Yale Law Sch. 2024) . 22, 23, 32

Eric S. Mullins et al., Thrombosis Risk in

Transgender Adolescents Receiving

Gender-Affirming Hormone Therapy,

147 Pediatrics e2020023549 (2021) ......................... 24

Serena

Nanda,

Gender

Diversity:

Crosscultural Variations (2014) ............................. 6

Nat’l Ass’n of Social Workers, Social Work

Speaks, Child Abuse and Neglect 35

(11th ed. 2018-2020) ................................................... 5

Nat’l Ass’n of Social Workers, Social Work

Speaks, Lesbian, Gay, and Bisexual

Issues 211 (11th ed. 2018-2020) ................................ 4

Nat’l Ass’n of Social Workers, Social Work

Speaks, Transgender and Gender

Nonconforming People 323 (11th ed.

2018-2020) .................................................................... 5

Nat’l Comm’n for the Prot. of Human

Subjects of Biomedical & Behav. Rsch.,

The Belmont Report: Ethical Principles

and Guidelines for the Protection of

Human Subjects of Research (Apr. 18,

1979) ........................................................................... 29

Johanna Olson-Kennedy et al., Chest

Reconstruction and Chest Dysphoria in

Transmasculine Minors and Young

Adults, 172 JAMA Pediatrics 431 (2018) .............. 25

Johanna Olson-Kennedy, Mental Health

Disparities Among Transgender Youth:

Rethinking the Role of Professionals, 170

JAMA Pediatrics 423 (2016) ................................... 24

Johanna Olson-Kennedy et al., Physiologic

Response

Gender-Affirming

Hormones Among Transgender Youth,

62 J. Adolescent Health 397 (2018) ........................ 24

George Ostapowicz et al., Results of a

Prospective Study of Acute Liver Failure

at 17 Tertiary Care Centers in the United

States, 137 Annals Internal Med. 947

(2002) .......................................................................... 26

xii

Press Release, Endocrine Soc’y, Endocrine

Society Statement in Support of GenderAffirming Care (May 8, 2024),

https://www.endocrine.org/news-and-ad

vocacy/news-room/2024/statement-in-su

pport-of-gender-affirming-care ............................. 23

Jason Rafferty, Am. Acad. of Pediatrics,

Ensuring Comprehensive Care and

Support for Transgender and GenderDiverse Children and Adolescents, 142

Pediatrics (reaffirmed 2023),

https://publications.aap.org/pediatrics/ar

ticle/142/4/e20182162/37381/EnsuringComprehensive-Care-and-Support-for........... 10–11

Elana Redfield et al., Prohibiting GenderAffirming Medical Care for Youth,

Williams

Institute

(Mar.

2023),

https://williamsinstitute.law.ucla.edu/wp

-content/uploads/Trans-Youth-HealthBans-Mar-2023.pdf ................................................... 31

Lynn Rew et al., Review: Puberty Blockers

for Transgender and Gender Diverse

Youth—A Critical Review of the

Literature, 26 Child & Adolescent Mental

Health 3 (2021) ................................................... 17, 21

Johanna Schmidt, Paradise Lost? Social

Change and Fa’afafine in Samoa, 51

Current Socio. 417 (2003) .......................................... 6

Julia C. Sorbara et al., Mental Health and

Timing of Gender-Affirming Care, 146

Pediatrics e20193600 (Oct. 2020) ..................... 16, 20

xiii

Substance Abuse & Mental Health Services

Administration, Ending Conversion

Therapy: Supporting and Affirming

LGBTQ Youth, HHS Publ’n No. (SMA)

15-4928 (Oct. 2015) ..................................................... 6

Jaime Swan et al., Mental Health and

Quality of Life Outcomes of GenderAffirming Surgery: A Systematic

Literature Review, 27 J. Gay & Lesbian

Mental Health 2 (2022) ............................................ 20

Russell B. Toomey et al., Gender-Affirming

Policies Support Transgender and

Gender Diverse Youth’s Health, Soc’y for

Rsch. in Child Dev. (Jan. 2022) .............................. 20

Russell B. Toomey et al. GenderNonconforming Lesbian, Gay, Bisexual,

and

Transgender

Youth:

School

Victimization

and

Young

Adult

Psychosocial

Adjustment,

Developmental Psych. 1580 (2010),

https://familyproject.sfsu.edu/sites/defau

lt/files/documents/FAP_School%20Victi

mization%20of%20Gender-nonconform

ing%20LGBT%20Youth.pdf ................................... 28

Diana M. Tordoff et al., Mental Health

Outcomes

Transgender

and

Nonbinary Youths Receiving GenderAffirming Care, 5 JAMA Network Open

e220978 (2022) ..................................................... 17, 21

xiv

Jack L. Turban et al., Access to GenderAffirming

Hormones

During

Adolescence

and

Mental

Health

Outcomes Among Transgender Adults,

17 PLoS ONE e0261039 (2022) .............................. 19

Jack L. Turban et al., Pubertal Suppression

for Transgender Youth and Risk of

Suicide, 145 Pediatrics e20191725 (2020) ....... 16, 21

Anna IR van der Miesen et al.,

Psychological

Functioning

Transgender Adolescents Before and

After

Gender-Affirmative

Care

Compared with Cisgender General

Population Peers, 66 J. Adolescent

Health 699 (2020) ..................................................... 21

Anna IR van der Miesen et al., ‘‘You Have

to Wait a Little Longer’’: Transgender

(Mental) Health at Risk as a

Consequence of Deferring GenderAffirming Treatments During COVID19, 49 Arch. Sex. Behav. 1395 (2020) ..................... 21

World Health Organization, Gender

Incongruence and Transgender Health

in the ICD, https://www.who.int/

standards/classifications/frequentlyasked-questions/gender-incongruenceand-transgender-health-in-the-icd (last

visited Aug. 30, 2024) ................................................ 7

WPATH,

WPATH

and

USPATH

Comment on the Cass Review (May 17,

2024), https://www.wpath.org/media/cms

/Documents/Public%20Policies/2024/17.0

5.24%20Response%20Cass%20Review%

20FINAL%20with%20ed%20note.pdf?_t

=1716075965 .............................................................. 23

WPATH, World Professional Association

for Transgender Health Standards of

Care for Transgender and Gender

Diverse People, Version 8 Frequently

Asked Questions (FAQs),

https://www.wpath.org/media/cms/Docu

ments/SOC%20v8/SOC 8%20FAQs%20

%20WEBSITE2.pdf#:~:text=This%20ve

rsion%20of%20the%20Standards%20of%

20Care%20uses,benefits%20and%20poss

ible%20harms%20of%20alternative%20c

are%20options .................................................... 11–12

INTEREST OF AMICI CURIAE1

Amicus curiae the American Psychological

Association (“APA”) submits this brief to provide the

Court with context regarding the state of scientific

knowledge about the efficacy and safety of genderaffirming care. 2 As the largest professional association

of psychologists in the United States, the APA is deeply

concerned about the mental health effects of banning

gender-affirming medical interventions. The APA has a

particular interest in this case given the emphasis on

mental health issues in the parties’ briefing and the

decision below.

The APA is a scientific and educational organization

dedicated to increasing and disseminating psychological

knowledge.

Its over 150,000 members include

researchers, educators, clinicians, consultants, and

students. The APA’s mission is to promote the

advancement, communication, and application of

psychological science and knowledge to benefit society

and improve lives. To that end, the APA has been, and

continues to be a strong and consistent advocate for

access to equal care and treatment for LGBTQ+

individuals. The APA has an interest in ensuring that

robust scientific research is used to examine the mental

Pursuant to Rule 37.6, counsel for amici curiae state that no

counsel for a party authored this brief in whole or in part, and no

person or entity other than amici or their counsel has made a

monetary contribution to the preparation or submission of this

brief.

The APA gratefully acknowledges the assistance of the following

psychologists in the preparation of this brief: Roberto L. Abreu,

Ph.D.; Stephanie Budge, Ph.D.; Francisco J. Sánchez, Ph.D.; and

Elliot A. Tebbe, Ph.D.

health effects of denying access to gender-affirming

medical care and to understand and refer to gender

dysphoria. In February 2024, the APA published a

policy statement affirming the APA’s support for

unobstructed access to healthcare and evidence-based

inclusive, clinical care for transgender, gender diverse,

and nonbinary individuals, and for increased public

accessibility to timely and accurate information founded

on clinical and psychological science. Moreover, the

APA is committed to correcting misinformation and

unfounded narratives that mischaracterize gender

dysphoria and gender-affirming care.

The APA has filed nearly 250 amicus briefs in federal

and state courts around the country. The APA has a

rigorous approval process for filing amicus briefs, the

touchstone being an assessment of whether there is

sufficient scientific research, data, and literature on a

question in a particular case such that the APA can

usefully contribute to the Court’s understanding and

resolution of that question. Given the attention the

decision below devoted to the mental health

consequences associated with access to gender-affirming

medical care, and the decision’s mischaracterization of

the available scientific literature on the topic, the APA

has a particular interest in this case.

Founded in 1952, amicus the American Counseling

Association (“ACA”) is a not-for-profit organization

dedicated to the growth and enhancement of the

counseling profession.

ACA provides education,

community, and professional development opportunities

for more than 58,000 members, including counselors in

various practice settings and counselors in training.

ACA engages in extensive advocacy for the profession

and for those whom it serves. ACA’s Code of Ethics

provides the foundation and direction for all that it does.

The preamble of the ACA 2014 Code of Ethics describes

the core professional values and the ethical principles

that guide decision-making and practice for the

counseling profession. These core professional values

include: enhancing human development throughout the

life span; honoring diversity and embracing a

multicultural approach in support of the worth, dignity,

potential, and uniqueness of people within their social

and cultural contexts; promoting social justice;

safeguarding the integrity of the counselor-client

relationship; and practicing in a competent and ethical

manner.

Amicus, the American Association for Marriage and

Family Therapy (“AAMFT”), founded in 1942, is a

national professional association representing the field

of marriage and family therapy and the professional

interests of over 81,000 marriage and family therapists

in the United States.

AAMFT stands as the

organizational thought leader in and advocate of

systemic and relational therapies. Endeavoring to meet

the evolving needs of its members and advance the

practice and profession of marriage and family therapy,

AAMFT is dedicated to expanding access and reducing

barriers to the service delivery of relationally centered

mental health care and making the world a better place

for the people and communities in which its members

serve and work.

AAMFT recognizes the adverse effects of antitransgender legislation on the livelihood of the

transgender and gender-diverse community. AAMFT

joins this brief for the reasons expressed in its

Transgender Resources for MFTs and in its 2004

Statement on Nonpathologizing Sexual Orientation and

related statements on its website.

Amicus, the National Association of Social Workers

(“NASW”), founded in 1955, is the largest association of

professional social workers in the United States with

110,000 members in 55 chapters. Its Tennessee Chapter

has over 1,700 members. NASW has worked to develop

high standards of social work practice while unifying the

social work profession.

NASW promulgates

professional policies, conducts research, publishes

professional studies and books, provides continuing

education, and enforces the NASW Code of Ethics. In

alignment with its mission to ensure the efficacy and

caliber of practicing social workers, NASW provides

resources and develops policy statements on issues of

importance to the social work profession. The NASW

National Committee on Lesbian, Gay, Bisexual,

Transgender, and Queer/Questioning + Issues develops,

reviews, and monitors NASW programs that

significantly affect LGBTQ+ individuals.

Consistent with those policy statements, NASW,

including its Tennessee Chapter, is committed to

advancing policies and practices that improve the status

and well-being of transgender, gender diverse,

nonbinary people. NASW strongly advocates for the

availability of culturally appropriate, comprehensive

health and mental health services across one’s life span.3

NASW supports the open availability of comprehensive

health, psychological, and social support services for

Nat’l Ass’n of Social Workers, Social Work Speaks, Lesbian, Gay,

and Bisexual Issues 211, 215-16 (11th ed. 2018-2020).

transgender and gender diverse people and their

families that are respectful and inclusive, provided by

skilled, educated professionals who have been trained to

work effectively with them.4 Furthermore, NASW

supports children’s rights to be treated with respect as

individuals; to receive culturally responsive services;

and to express their opinions about their lives and have

those opinions considered.5

Amicus, the Kentucky Psychological Association

(“KPA”) represents over 1,000 psychology practitioners,

trainees and students in the Commonwealth of

Kentucky. One of KPA’s main strategic pillars is

advocacy for psychology and psychologists. During the

2023 Kentucky General Assembly, KPA consistently

advocated against legislation targeting transgender

individuals.

KPA testified at multiple committee

hearings about the psychological science on genderaffirming care.

SUMMARY OF ARGUMENT

This case concerns Tennessee’s ban on genderaffirming medical treatment for minors. The decision

below asserts that the ban is justified by the State’s

interest in protecting adolescents. Amici write to

underscore that medical interventions for gender

dysphoria, like those at issue in Tennessee’s Senate Bill

1 (“S.B. 1”), are overwhelmingly accepted by the medical

community.

Nat’l Ass’n of Social Workers, Social Work Speaks, Transgender

and Gender Nonconforming People 323, 328 (11th ed. 2018-2020).

Nat’l Ass’n of Social Workers, Social Work Speaks, Child Abuse

and Neglect 35, 38-39 (11th ed. 2018-2020).

Diversity in gender identity and gender expression

is a part of the human experience.6 Throughout history,

there have always been children and adolescents who we

now recognize as transgender, gender diverse, and

nonbinary.7 The health care community’s understanding

of what it means to be transgender has advanced greatly

over the past century. It is now understood and widely

accepted within the medical and mental health

communities that an incongruence between one’s sex

and gender in and of itself implies no impairment in a

person’s judgment, mental health, or general social or

vocational capabilities.8

See, e.g., Johanna Schmidt, Paradise Lost? Social Change and

Fa’afafine in Samoa, 51 Current Socio. 417 (2003); Serena Nanda,

Gender Diversity: Crosscultural Variations (2014).

This brief recognizes that there are many diverse gender

experiences but will henceforth use the umbrella term “transgender

youth” to describe these varied groups.

Am. Psych. Ass’n, Report of the American Psychological Ass’n

Task Force on Appropriate Therapeutic Responses to Sexual

Orientation (2009), http://www.apa.org/pi/lgbt/resources/thera

peutic-response.pdf; Am. Psych. Ass’n, Guidelines for

Psychological Practice with Transgender and Gender

Nonconforming People, 70 Am. Psych. 832 (2015); Substance Abuse

& Mental Health Servs. Admin., Ending Conversion Therapy:

Supporting and Affirming LGBTQ Youth, HHS Publ’n No. (SMA)

15-4928 (Oct. 2015); Am. Psych. Ass’n, APA Resolution on Gender

Identity

Change

Efforts

(2021),

https://www.apa.org/

about/policy/resolution-gender-identity-change-efforts.pdf.

The

APA’s Resolution recognizes the distinction between transgender

identity, on the one hand, and the diagnosis of gender dysphoria, on

the other. Unlike transgender identity, gender dysphoria is

associated with “clinically significant distress or impairment in

social, occupational, or other important areas of functioning.” Am.

Gender dysphoria, the distress that arises related to

this incongruence, is, however, recognized as a medical

condition by major U.S. medical associations and the

World Health Organization.9 Not all transgender people

experience gender dysphoria.10 It is a highly

Gender dysphoria

individualized experience.11

manifests differently depending on age.12 For children,

gender dysphoria may look like significant distress or

impairment due to marked gender incongruence, and a

strong desire to be (or knowledge that one is) a gender

different from their sex assigned at birth.13

adolescents and adults, manifestations of gender

dysphoria may include the strong desire to be treated

and seen as the gender with which they identify, and the

strong desire for the primary and/or secondary sex

characteristics of that gender, as well as a desire to be

Psychiatric Ass’n, Diagnostic and Statistical Manual of Mental

Disorders: DSM-5 – TR, at 512–13 (2022).

DSM-5 – TR, supra note 8, at 512–13.

See Claire A. Coyne et al., Gender Dysphoria: Optimizing

Healthcare for Transgender and Gender Diverse Youth with a

Multidisciplinary Approach, 19 Neuropsych. Disease & Treatment

479 (2023), https://ncbi.nlm.nih.gov/pmc/articles/PMC9985385/;

World Health Organization, Gender Incongruence and

Transgender Health in the ICD, https://www.who.int/standards/

classifications/frequently-asked-questions/gender-incongruence-an

d-transgender-health-in-the-icd (last visited Aug. 30, 2024).

Id. at 483.

Gender Dysphoria, APA Dictionary of Psychology (updated Nov.

15, 2023), https://dictionary.apa.org/gender-dysphoria.

Id.

rid of the primary and secondary sex characteristics of

the gender assigned at birth.14

The medical consensus regarding accepted

treatment protocols for gender dysphoria aims to

alleviate the distress associated with the incongruence

between gender identity and birth-assigned sex.15 The

major medical and mental health organizations in the

United States follow guidelines that allow for medical

interventions for adolescents when deemed medically

appropriate by a licensed medical professional, and only

after careful examination by a licensed mental health

professional.16 The guidelines were developed by the

World Professional Association for Transgender Health

(“WPATH”), the leading association of medical

professionals treating transgender individuals, and the

Endocrine Society, a global community of more than

18,000 medical specialists around the world. Given their

scientific expertise on the subject, these organizations

are considered the standard-bearers in transgender

medical health.

Amici write to make this Court aware of the crucial

role that mental health professionals play in

safeguarding the careful administration of genderaffirming medical interventions for transgender youth

Id.

Am. Med. Ass’n, Comm. on Human Sexuality, Human Sexuality

38 (1972).

See GLAAD, Medical Association Statements in Support of

Health Care for Transgender People and Youth (June 26, 2024),

https://glaad.org/medical-association-statements-supporting-transyouth-healthcare-and-against-discriminatory/.

under the WPATH’s and Endocrine Society’s treatment

protocols.

First, amici explain that gender-affirming care is the

accepted protocol for treating gender dysphoria. Amici

explain the widely used standards of care and the

importance of medical interventions for transgender

mental health, as well as the role of mental health

professionals in evaluating the appropriateness of

medical interventions.

Second, amici explain that gender-affirming medical

care is effective, evidence-based, and safe. Studies show

that gender-affirming medical care has substantial

positive effects for transgender youth, including

reducing psychological distress as well as improving

quality of life. In fact, multiple peer-reviewed studies

have shown that an overwhelming number of

adolescents with gender dysphoria who receive

medications for pubertal suppression and/or hormone

therapy are at less risk for anxiety, depression, low selfesteem, or self-harm.

Third, amici write to emphasize the long-term

negative mental health consequences that banning

gender-affirming medical treatments would have on

transgender youth in Tennessee.

Without the

appropriate support and treatment for gender

dysphoria, transgender youth as a whole face increased

rates of negative mental health outcomes, substance use,

and suicide.

Fourth, amici write to stress that Tennessee’s effort

to ban gender-affirming medical care jeopardizes the

role of mental health (and medical) providers in

assessing what evidence-based treatments are

appropriate for their patients. Psychologists and other

mental health practitioners are guided by ethical

principles, including the principles of justice, do no harm,

beneficence, and dignity for people’s rights. Competent

and ethical care requires providers to be able to access

the full panoply of treatment protocols accepted under

the WPATH guidelines. As some of the largest leading

organizations of mental health professionals in the

country, amici write to ensure the Court understands

the serious impact that legislation banning genderaffirming medical care for minors would have on the

medical community, and in particular on mental health

professionals who seek to provide the best standards of

care to their patients.

Finally, amici respond to the decision below, which

relied on misleading and unfounded narratives that

create a distorted perception of the psychological and

medical support necessary for transgender youth.

ARGUMENT

I. Gender-Affirming Care Is the Accepted Treatment

Protocol for Treating Children and Adolescents

with Gender Dysphoria.

Major medical and mental health organizations in the

United States, including amici, recognize the WPATH

Standards of Care and the Endocrine Society Guidelines

as the appropriate treatments for individuals diagnosed

with gender dysphoria.17 The WPATH Standards

See, e.g., Jason Rafferty, Am. Acad. of Pediatrics, Ensuring

Comprehensive Care and Support for Transgender and GenderDiverse Children and Adolescents, 142 Pediatrics at 2 (reaffirmed

explain that the recommended treatment is to provide

gender-affirming care, which is highly individualized and

includes a range of accepted treatment options.18 The

guidelines are highly tailored: recommendations are

different for children, adolescents, and adults.19 The

WPATH Standards reflect the consensus in expert

opinion among professionals in this field based on their

collective clinical experience as well as a large body of

research.20

2023), https://publications.aap.org/pediatrics/article/142/4/e2018216

2/37381/Ensuring-Comprehensive-Care-and-Support-for.

E. Coleman et al., World Professional Association for

Transgender Health (“WPATH”), Standards of Care for the Health

of Transgender and Gender Diverse People, Version 8, 23 Int’l J.

Transgender Health S1, S7 (Sept. 2022), https://www.tandfonline.

com/doi/pdf/10.1080/26895269.2022.2100644 [hereinafter WPATH

Standards of Care]; William Byne et al., Assessment and Treatment

of Gender Dysphoria and Gender Variant Patients: A Primer for

Psychiatrists, 175 Am. J. Psychiatry 1046 (2018).

Am. Psych. Ass’n, Report of the APA Task Force on Gender

Identity and Gender Variance, 35 (2009), https://www.apa.org/

pi/lgbt/resources/policy/gender-identity-report.pdf.

Id. at 32. The WPATH Standards of Care are developed by a

multidisciplinary team of clinicians, researchers and stakeholders

using a clearly defined process. The Standards of Care are

developed using an evidence-based approach.

Adopted

recommendations require 75% approval of members and were

“informed by a systematic review of evidence and an assessment of

the benefits and possible harms of alternative care options.”

WPATH, World Professional Association for Transgender Health

Standards of Care for Transgender and Gender Diverse People,

Version

Frequently

Asked Questions (FAQs),

https://www.wpath.org/media/cms/Documents/SOC%20v8/SOC 8

%20FAQs%20 %20WEBSITE2.pdf#:~:text=This%20version%20of

The WPATH Standards explain that, often, a

combination of approaches is needed to provide

comprehensive, gender-affirming care. The Standards

emphasize that “there is no ‘one-size-fits-all’ approach”

to gender-affirming healthcare, but rather, that a

patient-centered care model should be used to support

gender-affirming interventions.21 These interventions

can include changes to name and gender presentation,

hormone therapy, surgery, and mental health support,

among others.22 The Standards further make clear that

the availability of treatments depends on the age of the

patient, and that no medication for pubertal suppression

or surgical interventions are considered appropriate

before a person reaches puberty.23 Puberty is defined

scientifically by the Tanner staging method, which is “an

objective classification system that providers use to

document and track the development and sequence of

secondary sex characteristics of children during

puberty.”24 The Tanner stages range from Tanner Stage

%20the%20Standards%20of%20Care%20uses,benefits%20and%20

possible%20harms%20of%20alternative%20care%20options.

WPATH Standards of Care, supra note 18, at S7; see also id. at

S60 (“The range of youth experiences of gender incongruence

necessitates professionals provide a range of treatments or

interventions based on the individual’s needs.”).

Id. at S60.

Id. at S48 (“The adolescent has reached Tanner stage 2 of puberty

for pubertal suppression to be initiated.”); see id. at S48-S60

(explaining that “decisions to move forward with medical and

surgical treatments should be made carefully,” and listing

requirements).

Mickey Emmanuel & Brooke R. Bokor, Tanner Stages, StatPearls

(last updated Dec. 11, 2022), https://www.ncbi.nlm.nih.gov/books/

1 (pre-pubertal) to Tanner Stage 5 (final adult form).25

Providers use Tanner staging to determine when

medication for pubertal suppression and/or other

medical interventions may be appropriate.26

Mental health professionals play a critical role in

ensuring that gender-affirming medical care is both

individualized and carefully administered.

approaches to pediatric transgender healthcare have

shifted toward a gender-affirming model, the role of

mental health professionals has grown more important

in helping to support transgender children and adults.27

NBK470280/; see also Jonathan T. Avila, Normal Adolescent

Growth and Development, in Encyclopedia of Child and Adolescent

Health: Biological Development and Physical Health 735 (Bonnie

Halpern-Felsher ed. et al., 2023).

Emmanuel & Bokor, supra note 24.

See WPATH Standards of Care, supra note 18 at S48; Coyne et

al., supra note 10, at 484.

See WPATH Standards of Care, supra note 18 at S48 (“If possible,

[transgender] adolescents should have access to experts in pediatric

transgender health from multiple disciplines including primary

care, endocrinology, fertility, mental health, voice, social work,

spiritual support, and surgery.”); Wylie C. Hembree et al.,

Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent

Persons: An Endocrine Society* Clinical Practice Guideline, 102 J.

Clinical Endocrin. & Metabolism 3869, 3870 (2017) (recommending

that “an expert multi-disciplinary team comprised of medical

professionals and mental health professionals” manage treatment

for transgender adolescents”) [hereinafter Endocrine Society

Guidelines]; Lore M. Dickey et al., Univ. of Cal. S.F., Transgender

Care, Mental Health Considerations with Transgender and Gender

Nonconforming Clients, https://transcare.ucsf.edu/guidelines/

mental-health (noting that “[e]very intake for [gender-affirming]

Mental health professionals diagnose and treat gender

dysphoria, support gender exploration, and affirm

gender identity.28

Importantly, they work with

transgender youth and their families to understand,

refer, and support them in seeking medical interventions

if appropriate.29

The WPATH Standards and the Endocrine Society

Guidelines recommend the involvement of mental health

practitioners in many of the steps required before a

transgender adolescent can access gender-affirming

According to both Standards,

medical care.30

transgender adolescents should not access genderaffirming medical care without certain mental health

assessments and support.31 Mental health professionals

care should include a mental health history and an assessment for

active mental health concerns”).

See, e.g., Report of the APA Task Force on Gender Identity and

Gender Variance, supra note 19 (creating guidelines for

psychologists and other mental health professionals to provide

culturally competent psychological support for transgender adults

and youth); Endocrine Society Guidelines, supra note 27 at 3870

(“We advise that decisions regarding the social transition of

prepubertal youths with [gender dysphoria]/gender incongruence

are made with the assistance of [a mental health practitioner] or

another experienced professional.”).

See, e.g., Endocrine Society Guidelines, supra note 27 at 3870

(explaining that physicians treating gender dysphoria must

“confirm the criteria for treatment used by the referring mental

health practitioner and collaborate with them in decisions” about

gender-affirming medical care).

WPATH Standards of Care, supra note 18 at S48; Endocrine

Society Guidelines, supra note 27 at 3870.

Endocrine Society Guidelines, supra note 27 at 3870–71

(explaining the role of mental health professionals and other

aid in these assessments by, for example, assessing

whether an adolescent: (1) meets the diagnostic criteria

of gender incongruence; (2) has the emotional and

cognitive maturity required to provide informed

consent/assent for the treatment; (3) has any mental

health concerns that may interfere with diagnostic

clarity, capacity to consent, and gender-affirming

medical treatments, and if these concerns have been

addressed.32 Both the WPATH Standards of Care and

the Endocrine Society Guidelines require that all of

these steps, among others, be met before an adolescent

is able to access gender-affirming medical care. Some

transgender youth may undergo all available medical

interventions, while others may opt for a few, and still

others may opt for none.33 Ultimately, the goal of

gender-affirming care is to holistically address the

social, mental, and medical health needs of transgender

people while affirming their gender identity.34

II. Gender-Affirming Medical Care Is Effective,

Evidence-Based, and Safe.

Leading medical and mental health professions

support gender-affirming care, recognizing that gender

identities are diverse and that rigid notions of sex and

clinicians in evaluating transgender youth before providing genderaffirming medical care); WPATH Standards of Care, supra note 18

at S48 (same).

WPATH Standards of Care, supra note 18 at S48.

APA Resolution on Gender Identity Change Efforts, supra note

8, at 1; WPATH Standards of Care, supra note 18, at S81.

APA Resolution on Gender Identity Change Efforts, supra note

8, at 1.

gender are barriers to good healthcare for all patients.35

For example, the American Medical Association, the

American Academy of Pediatrics, and the American

Psychiatric

Association—all

major

medical

associations—recognize that gender-affirming care is a

critical component for ensuring that transgender youth

lead healthy lives.36 Together, this means that hundreds

of thousands of doctors, researchers, and mental health

professionals support gender-affirming care.

That is because gender-affirming care, including the

medications prescribed for pubertal suppression and

hormone therapy at issue in Tennessee’s S.B. 1, is

effective, evidence-based, and safe.

First, gender-affirming care is effective: it leads to a

decrease in suicidality, depression, and anxiety, as well

as an increase in overall psychological functioning and

mental well-being. There is substantial research that

supports the efficacy of gender-affirming care in

improving positive mental health outcomes for

transgender youth who are able to access that care.37

See Am. Psych. Ass’n, APA Policy Statement on Affirming

Evidence-Based Inclusive Care for Transgender, Gender Diverse,

and Nonbinary Individuals, Addressing Misinformation, and the

Role of Psychological Practice and Science (Feb. 2024),

https://www.apa.org/about/policy/transgender-nonbinary-inclusive

-care.pdf; Guidelines for Psychological Practice with Transgender

and Gender Nonconforming People, supra note 8.

See GLAAD, supra note 16.

Julia C. Sorbara et al., Mental Health and Timing of GenderAffirming Care, 146 Pediatrics e20193600 (Oct. 2020); Jack L.

Turban et al., Pubertal Suppression for Transgender Youth and

Risk of Suicide, 145 Pediatrics e20191725 (2020) (using a crosssectional survey of more than 20,000 transgender adults to examine

Access to gender-affirming care, including medical

interventions for pubertal suppression and/or hormone

therapy, has a positive relationship with the mental

health of transgender adolescents and lowers the risks

of depression and suicide. 38 These medical interventions

self-reported history of pubertal suppression during adolescence,

finding a “significant inverse association between treatment with

pubertal suppression during adolescence and lifetime suicidal

ideation among transgender adults who ever wanted this

treatment”); Diana M. Tordoff et al., Mental Health Outcomes in

Transgender and Nonbinary Youths Receiving Gender-Affirming

Care, 5 JAMA Network Open e220978 (2022) (performing study on

over 100 transgender youth and finding that access to genderaffirming care was associated with mitigation of mental health

disparities among transgender youth over one year); Lynn Rew et

al., Review: Puberty Blockers for Transgender and Gender Diverse

Youth—A Critical Review of the Literature, 26 Child & Adolescent

Mental Health 3, 12 (2021) (conducting a systematic review of

literature about the use of puberty-blocking hormones among

transgender youth and finding that the “research supports the use

of puberty suppression in early adolescents who are carefully

screened for gender dysphoria and who have reached an early stage

of pubertal development”).

See, e.g., Luke R. Allen et al., Well-Being and Suicidality Among

Transgender Youth After Gender-Affirming Hormones, 7 Clinical

Prac. Pediatric Psych. 302 (Sept. 2019) (performing a longitudinal

evaluation of the effectiveness of gender-affirming hormones for

forty-seven youth and finding a “significant increase in levels of

general well-being and a significant decrease in levels of suicidality”

after gender-affirming hormones); Diane Chen et al., Psychosocial

Functioning in Transgender Youth after 2 Years or Hormones, 388

New Eng. J. Med. 240 (2023) (finding that after two-year study

involving over 300 transgender youth, administration of genderaffirming hormones appearance congruence, and life satisfaction

increased, and depression and anxiety symptoms decreased);

Annelou L.C. de Vries et al., Puberty Suppression in Adolescents

with Gender Identity Disorder: A Prospective Follow-Up Study, 8

are available only to youth who have reached puberty,

and the decision of whether to begin a course of

treatment that includes medical intervention is made

carefully, by medical and mental health providers,

parents, and with input as appropriate from transgender

adolescents themselves.39

One 2020 survey of over 11,000 transgender

adolescents found that use of gender-affirming hormone

therapy was associated with lower risk of depression

and suicide for those who received therapy as compared

to adolescents who wanted therapy but did not receive

it.40 Another survey, analyzing the results of six

J. Sex. Med. 2276 (2011) (finding that behavioral and emotional

problems and depressive symptoms decreased, while general

functioning improved significantly during puberty suppression).

Tennessee’s law also infringes on parents’ rights to make medical

decisions for their children. See, e.g., Kacie M. Kidd et al., “This

Could Mean Death for My Child”: Parent Perspectives on Laws

Banning Gender-Affirming Care for Transgender Adolescents, 68

J. Adolescent Health 1082 (2021) (summarizing a study of parents

and caregivers of transgender youth who felt they “were the only

ones who should have the right to make important decisions about

medical interventions for their child”); Alexa Martin-Storey et al.,

Barriers to Health Care and Mental Health Among Parents of

Transgender and Gender Diverse Youth, Transgender Health (July

2024) (conducting study showing that limiting access to genderaffirming health care for transgender youth is associated with

“higher parent anxiety and depressive symptoms” for parents of

transgender youth); Roberto L. Abreu et al., “I Am Afraid for

Those Kids Who Might Find Death Preferable”: Parental Figures’

Reactions and Coping Strategies to Bans on Gender Affirming

Care for Transgender and Gender Diverse Youth, 9 Psych. Sex.

Orientation & Gender Diversity 500 (2020).

Amy E. Green et al., Association of Gender-Affirming Hormone

Therapy With Depression, Thoughts of Suicide, and Attempted

longitudinal cohort studies examining the impact of

access to gender-affirming hormones during adolescence

on the mental health outcomes among transgender

adults, found improvement in mental health, decreases

in internalizing psychopathology, improved general

well-being, and decreased suicidality.41 This study

compared a group of adults who, as adolescents, received

access to gender-affirming hormones with a group of

adults who did not receive hormone treatment during

adolescence, and concluded that access to genderaffirming hormone healthcare was associated with more

favorable mental health outcomes reported in

adulthood.42

Access to gender-affirming medical interventions

improves mental health outcomes for transgender

adolescents, which is especially critical because the rates

of suicidal ideation and depression among the

transgender population are much higher than the

general population.43 In fact, transgender adolescents

Suicide Among Transgender and Nonbinary Youth, 70 J.

Adolescent Health 643 (2022).

Jack L. Turban et al., Access to Gender-Affirming Hormones

During Adolescence and Mental Health Outcomes Among

Transgender Adults, 17 PLoS ONE e0261039 (2022).

Id.

Christal Achille et al., Longitudinal Impact of Gender-Affirming

Endocrine Intervention on the Mental Health and Well-Being of

Transgender Youths: Preliminary Results, Int’l J. Pediatric

Endocrinology (2020); Terryann C. Clark et al., The Health and

Well-Being of Transgender High School Students: Results from the

New Zealand Adolescent Health Survey, 55 J. Adolescent Health

93 (2014).

who have access to gender-affirming medical care

experience improvements in mental health and often

show mental health outcomes comparable to their

cisgender peers.44 Moreover, for those adolescents

who—with parental consent—are able to access genderaffirming surgeries, such interventions are associated

with a reduction in anxiety, depression, and suicide

attempts, as well as an increase in life satisfaction.45

Second, gender-affirming care is a well-established,

evidenced-based model of care for transgender youth.46

Evidence-based practice in psychology is the integration

of the best available research with clinical expertise in the

context of patient characteristics, culture, and

preferences.47 Gender-affirming care is evidence-based

Russell B. Toomey et al., Gender-Affirming Policies Support

Transgender and Gender Diverse Youth’s Health, Soc’y for Rsch. in

Child Dev. (Jan. 2022).

Sorbara et al., supra note 37; Anthony N. Almazan & Alex S.

Keuroghlian, Association Between Gender-Affirming Surgeries

and Mental Health Outcomes, 156 JAMA Surgery 611 (2021);

Simone Mahfouda et al., Gender-Affirming Hormones and Surgery

in Transgender Children and Adolescents, 7 Lancet Diabetes

Endocrin. 484 (2019); Jaime Swan et al., Mental Health and Quality

of Life Outcomes of Gender-Affirming Surgery: A Systematic

Literature Review, 27 J. Gay & Lesbian Mental Health 2 (2022).

Laura L. Kimberly et al., Ethical Issues in Gender-Affirming

Care for Youth, 142 Pediatrics e20181537 (2018); Debra A. Hope &

Jae A. Puckett, Bans on Evidence-Based Care for Transgender and

Gender Diverse People Present Risks for Clients and Dilemmas for

Mental Health Providers, 31 Cognitive & Behav. Prac. 15 (2023).

Am. Psych. Ass’n, Policy Statement on Evidence-Based Practice

in Psychology, https://www.apa.org/practice/guidelines/evidencebased-statement (last updated Apr. 2021).

because it is rooted in a sizeable body of evidence drawn

from a variety of research designs and methodologies that

attests to its effectiveness. Many scientifically rigorous

studies have demonstrated improvements in mental

health for transgender youth who received genderaffirming care.48 As to gender-affirming hormones in

particular, there have been at least six longitudinal cohort

studies examining the impact of gender-affirming

hormones on the mental health of transgender

adolescents.49 All six of these longitudinal studies showed

improvement in mental health, including “decreases in

internalizing psychopathology, improved general

wellbeing, and decreased suicidality.”50

Respondents question a lack of longer-term, larger

studies on the impacts of gender-affirming medical

treatment. However, the availability of such studies is

not realistic or appropriate for several reasons and the

See, e.g., Anna IR van der Miesen et al., Psychological

Functioning in Transgender Adolescents Before and After GenderAffirmative Care Compared with Cisgender General Population

Peers, 66 J. Adolescent Health 699 (2020); cf. Anna IR van der

Miesen et al., ‘‘You Have to Wait a Little Longer’’: Transgender

(Mental) Health at Risk as a Consequence of Deferring GenderAffirming Treatments During COVID-19, 49 Arch. Sex. Behav.

1395 (2020) (demonstrating negative mental effects of deferral of

most gender-affirming (medical) treatments); Greta R. Bauer et al.,

Intervenable Factors Associated with Suicide Risk in Transgender

Persons: A Respondent Driven Sampling Study in Ontario,

Canada, 15 BMC Pub. Health 525 (2015); Allen et al., supra note 38;

Turban et al., supra note 37; Chen et al., supra note 38; Tordoff et

al., supra note 37, Rew et al., supra note 37.

Turban et al., supra note 37.

Id.

lack of availability of these studies does not call the

safety of gender-affirming medical treatment into

question. For example, randomized-controlled trials

(“RCTs”) can pose ethical issues for transgender youth,

and the results of such studies may be of limited utility

due to their lack of generalizability.51 Moreover, as a

group of highly experienced researchers and pediatric

clinicians with experience in transgender healthcare has

pointed out, many pediatric medical treatments are

based on necessarily limited research due to time

constraints and the urgency of certain treatments.52

RCTs require randomizing participants between at least two

groups, one of which receives the proposed intervention and one of

which does not (also known as “masking”). Florence Ashley et al.,

Randomized-Controlled

Trials

are

Methodologically

Inappropriate in Adolescent Transgender Healthcare, 25 Int’l J.

Transgender Health 407 (2024) (describing the limitations of

randomized-controlled trials in adolescent transgender healthcare

because of ethical concerns, problems of generalizability, and the

inability to mask treatment due to the physiological effects of

gender-affirming interventions). Moreover, masking in an RCT

examining the effects of medication prescribed for pubertal

suppression would be impossible—a youth who received such

medication would quickly notice “physiologically evident effects.”

de Vries et al., supra note 38, at 2282. RCTs could be beneficial in

other ways, such as by comparing different types of hormone

therapies (estrogen versus progesterone, for example) or different

types of administrations (topical versus injection). But, the utility

of RCTs demanded by opponents of gender-affirming care is limited

in this context.

Meredithe McNamara et al., An Evidence-Based Critique of “The

Cass Review” on Gender-affirming Care for Adolescent Gender

Dysphoria, 14–15 (Yale Law Sch. 2024) (responding to the “Cass

Review,” the UK National Health Service’s 2024 Report on genderaffirming care for youth). Though the Cass Review has been cited

by opponents of gender-affirming care as supporting their position,

In the absence of larger, randomized-controlled

trials, medical providers may appropriately rely on

complementary and well-designed observational

studies, of which there are many, as cited herein, that

support the safety and effectiveness of gender-affirming

care in improving the mental health and quality of life

for transgender youth.

Recommending genderaffirming medical care requires providers to weigh the

risks and benefits for each patient, and obtain informed

consent, as with any other medical treatment. Genderaffirming care is informed by sound evidence and the

international guidelines created by WPATH53 and the

Endocrine Society.54

Third, gender-affirming medical care is safe.

Multiple studies demonstrate the safety of genderMcNamara, et al. have made clear that the Cass Review is “not an

endorsement of a ban on medical care for transgender youth,” see

id. at 4, because it “favorably describes the provision of

individualized, evidence-informed clinical care, including robust

assessments of the various medical and non-medical domains of

support that an adolescent may require,” id. at 5. The Cass Review

was undertaken by Dr. Hillary Cass, who had “negligible prior

knowledge or clinical experience of trans and gender diverse youth

or . . . transgender medicine and surgery.” See WPATH and

USPATH Comment on the Cass Review (May 17, 2024),

https://www.wpath.org/media/cms/Documents/Public%20Policies/2

024/17.05.24%20Response%20Cass%20Review%20FINAL%20wit

h%20ed%20note.pdf?_t=1716075965.

WPATH Standards of Care, supra note 18.

Endocrine Society Guidelines, supra note 27; Press Release,

Endocrine Soc’y, Endocrine Society Statement in Support of

Gender-Affirming Care (May 8, 2024), https://www.endocrine.

org/news-and-advocacy/news-room/2024/statement-in-support-ofgender-affirming-care.

affirming medical care for transgender youth.55 The

medical interventions available to transgender

adolescents are supported by research demonstrating

their safety and buttressed by careful standards that

require informed consent for patients seeking

treatment, including informed parental consent for

patients under 18. Gender-affirming treatments such as

medication for pubertal suppression and genderaffirming hormones have a well-established history of

use among cisgender youth with certain medical

conditions (for example, in

underproduction of

hormones or precocious puberty).56 And, pubertal

suppression is reversible insofar as youth who terminate

their course of treatment will resume endogenous

puberty.57 Medications for pubertal suppression merely

Karine Khatchadourian et al., Clinical Management of Youth

with Gender Dysphoria in Vancouver, 164 J. Pediatrics 906 (2014);

Eric S. Mullins et al., Thrombosis Risk in Transgender Adolescents

Receiving Gender-Affirming Hormone Therapy, 147 Pediatrics

e2020023549 (2021) (finding that gender-affirming hormone therapy

“does not carry a significant risk of thrombosis in the short-term,

even with the presence of preexisting thrombosis risk factors”);

Johanna Olson-Kennedy, Mental Health Disparities Among

Transgender Youth: Rethinking the Role of Professionals, 170

JAMA Pediatrics 423 (2016); Johanna Olson-Kennedy et al.,

Physiologic Response to Gender-Affirming Hormones Among

Transgender Youth, 62 J. Adolescent Health 397 (2018).

Rosalia Costa et al., Psychological Support, Puberty Suppression,

and Psychosocial Functioning in Adolescents with Gender

Dysphoria, 12 J. Sex. Med. 2206 (2015); Annelou L.C. de Vries et al.,

Young Adult Psychological Outcome After Puberty Suppression

and Gender Reassignment, 134 Pediatrics 1 (2014); Endocrine

Society Guidelines, supra note 27.

Endocrine Society Guidelines, supra note 27.

provide more time for youth to “mature and consider,

along with their parents and treatment team,” whether

additional medical interventions are appropriate.58

Adolescents who have progressed further in puberty

may receive gender-affirming hormones, the effects of

which are partially reversible.59 And, most surgical

interventions are offered to adults only, save for chest

masculinization surgery, which is only available to

transgender adolescents experiencing “significant and

impairing chest dysphoria,” and only with the support

and consent of their parents.60

The WPATH Standards require that youth seeking

gender-affirming medical and surgical treatments

demonstrate the emotional and cognitive maturity

required to participate in the consent process, and that

any mental health concerns that may interfere with

diagnostic clarity, capacity to consent, and genderaffirming medical treatments have been addressed

before beginning treatment.61

Similarly, medical

providers must inform transgender adolescents of the

potential side effects and repercussions of certain

interventions, such as the potential loss of fertility and

the available options to preserve fertility, all of which

must be discussed in the context of the adolescent’s

Coyne et al., supra note 10, at 483.

Id. at 484.

Id.; Johanna Olson-Kennedy et al., Chest Reconstruction and

Chest Dysphoria in Transmasculine Minors and Young Adults,

172 JAMA Pediatrics 431 (2018).

WPATH Standards of Care, supra note 18, at S48; Guidelines for

Psychological Practice with Transgender and Gender

Nonconforming People, supra note 8, at 845–46.

stage of pubertal development.62

Of course, all

medications may have side effects,63 but the scientific

evidence does not justify a categorical ban on medical

interventions for transgender youth, particularly when

the same interventions are used safely for a population

of youth who are not transgender.

III. Banning Gender-Affirming Medical Care Would

Irreparably Harm the Mental Health and

Emotional Well-Being of Transgender Youth.

Tennessee’s S.B. 1 denies adolescents with gender

dysphoria

access

evidence-based

medical

interventions that a licensed medical professional has

deemed medically necessary to treat gender dysphoria.

That lack of access to medically necessary interventions

grounded in science and endorsed by the medical and

mental health communities, coupled with the

increasingly hostile anti-transgender rhetoric that fuels

these restrictions, will significantly affect the mental

health of transgender youth living and seeking access to

care in Tennessee.64

WPATH Standards of Care, supra note 18, at S48; Endocrine

Society Guidelines, supra note 27, at 3871.

See, e.g., George Ostapowicz et al., Results of a Prospective Study

of Acute Liver Failure at 17 Tertiary Care Centers in the United

States, 137 Annals Internal Med. 947 (2002) (concluding that

acetaminophen overdose is the most frequent cause of acute liver

failure).

Mark Hatzenbuehler et al., Proposition 8 and Homophobic

Bullying in California, 143 Pediatrics e20182116 (2019); Roberto L.

Abreu et al., Impact of Gender-Affirming Care Bans on

Transgender and Gender Diverse Youth: Parental Figures’

Perspective, 36 J. Fam. Psych. 643 (2022).

Anti-transgender policies like Tennessee’s law can

exacerbate the risk of “anxiety and depression, low selfesteem, engaging in self-injurious behaviors, suicide,

substance use, homelessness, and eating disorders

among other adverse outcomes” that many transgender

individuals face.65 One study concluded that “living in

states with discriminatory policies . . . was associated

with a statistically significant increase in the number of

psychiatric disorder diagnoses.”66 The APA has studied

the burden that stigma and discriminatory legislation

have on transgender youth, and concluded that “the

notable burden of stigma and discrimination affects

minority persons’ health and well-being and generates

health disparities.”67

Exclusionary policies have a particularly negative

effect on the social and emotional development of

children and adolescents. Such policies can produce and

compound the stigma and discrimination that

Am. Psych. Ass’n & Nat’l Ass’n of Sch. Psychs., Resolution on

Gender and Sexual Orientation Diversity in Children and

Adolescents in Schools (2015), https://www.apa.org/about/policy/or

ientation-diversity [hereinafter APA/NASP Resolution].

Judith Bradford et al., Experiences of Transgender-Related

Discrimination and Implications for Health: Results From the

Virginia Transgender Health Initiative Study, 103 Am. J. Pub.

Health 1820, 1827 (2013), https://www.ncbi.nlm.nih.gov/pmc/article

s/PMC3780721/. See also Abreu et al., supra note 64.

APA/NASP Resolution, supra note 65; see also Jaclyn M. White

Hughto et al., Transgender Stigma and Health: A Critical Review

of Stigma Determinants, Mechanisms, and Interventions, 147 Soc.

Sci. Med. 222, 223, 226–27 (2015) (discussing how anti-transgender

stigma is “linked to adverse health outcomes including depression,

anxiety, suicidality, [and] substance abuse”).

transgender children and adolescents face in a school

environment, which in turn is associated with an

increased risk of post-traumatic stress disorder,

depression, anxiety, and suicidality in adulthood.68 In

short, banning access to gender-affirming medical

treatments for children and adolescents will have a

deleterious and long-term impact on their mental, social,

and emotional well-being.

IV. Banning Gender-Affirming Medical Care Disrupts

the Role of Providers in Offering Evidence-Based,

Medically Accepted Care.

The Tennessee law at issue also threatens medical

providers’ ability to engage in beneficent clinical

practices, placing psychologists and other mental health

providers in a compromising position in which abiding by

the law could require them to violate their ethical code

of conduct to pursue the best medically accepted

treatment options for their patients.69

Russell B. Toomey et al., Gender-Nonconforming Lesbian, Gay,

Bisexual, and Transgender Youth: School Victimization and

Young Adult Psychosocial Adjustment, 46 Developmental Psych.

1580, 1580-82 (2010), https://familyproject.sfsu.edu/sites/default

/files/documents/FAP_School%20Victimization%20of%20Gender-n

onconforming%20LGBT%20Youth.pdf; see also APA/NASP

Resolution, supra note 65; Harry Barbee et al., Anti-Transgender

Legislation—A Public Health Concern for Transgender Youth, 176

JAMA Pediatrics 125 (2022) (“Systemic marginalization may have

uniquely harmful effects on transgender youths’ health.”).

See, e.g., Landon D. Hughes et al., “These Laws Will Be

Devastating”: Provider Perspectives on Legislation Banning

Gender-Affirming Care for Transgender Adolescents, 69 J.

Adolescent Health 976 (2021) (surveying over 100 providers of

gender-affirming care and finding that fear that legislation banning

Specifically,

gender-affirming

medical

and

psychological care has been shown to mitigate the

negative effects of gender dysphoria, satisfying the

ethical principles of beneficence and nonmaleficence.70

Laws prohibiting transgender adolescents from

accessing medical interventions that may be a crucial

component of their individualized treatment for genderaffirming care are also inconsistent with the general

medical ethics principle of integrity. The principle of

integrity requires psychologists to “seek to promote

accuracy, honesty, and truthfulness in the science,

teaching, and practice of psychology.”71 Psychologists

and social workers who provide truthful, evidence-based

gender-affirming care would lead to worsening mental health

including increased risk for suicides among transgender youth and

interfere with providers’ ability to practice evidence-based

medicine); Damian Krebs et al., Care for Transgender Young

People, 95 Hormone Rsch. Paediatrics 405, 406 (2022) (noting it is

“fundamental that clinicians ensure that their practices affirm the

young people that they serve as nonaffirming healthcare

experiences or environments may deter [transgender youth] from

seeking healthcare”).

Beneficence is the principle that demands that people be “treated

in an ethical manner not only by respecting their decisions and

protecting them from harm, but also by making efforts to secure

their well-being.” Nat’l Comm’n for the Prot. of Human Subjects of

Biomedical & Behav. Rsch., The Belmont Report: Ethical

Principles and Guidelines for the Protection of Human Subjects of

Research (Apr. 18, 1979). Nonmaleficence is the principle that

demands that medical and mental health professionals “do no

harm.”

Am Psych. Ass’n, Ethical Principles of Psychologists and Code of

Conduct at 3–4 (effective Jan. 1, 2017), https://www.apa.org/ethics/

code/ethics-code-2017.pdf [hereinafter APA, 2017].

information to patients may risk being charged with

“aiding and abetting” criminalized medical care.72 Laws

or regulations that cast gender-affirming mental health

care as “aiding and abetting” could create a conflict with

medical professionals’ ethics code, which directs that

“psychologists … take reasonable steps to resolve the

conflict consistent with the General Principles and

Ethical Standards of the Ethics Code.”73

Finally, legislation that prohibits gender-affirming

medical interventions risks violating the APA’s Code of

Ethics’ and the NASW Code of Ethics’ principle of

respect for people’s rights and dignity.74 The principle of

respect for people’s rights and dignity affirms the rights

of individuals to privacy, confidentiality, and selfdetermination, as well as respect for individual

differences including gender identity.75 Tennessee’s law

See, e.g., Arkansas H.B. 1540 (2021). H.B. 1540 would have

prohibited medical providers from offering minors gender-affirming

care or providing referrals, or risk discipline by relevant licensing

entities; see also Lindsey Dawson et al., Youth Access to Gender

Affirming Care: The Federal and State Policy Landscape, Kaiser

Fam. Found. (June 1, 2022) (noting that “since January 2022 15

states introduced a total of 25 bills that would restrict access to

gender-affirming care for youth,” and that some provisions would:

“criminalize or impose/permit professional disciplinary action (e.g.

revoking or suspending licensure) of health professionals providing

gender-affirming care to minors, in some cases labeling such

services as child abuse”).

APA, 2017, supra note 71, at 4; see also Anthony W.P. Flynn et

al., When the Political is Professional: Civil Disobedience in

Psychology, 76 Am. Psych. 1217 (2021).

APA, 2017, supra note 71, at 4.

See Beth A. Clark & Alice Virani, This Wasn’t a Split-Second

Decision: An Empirical Ethical Analysis of Transgender Youth

essentially requires the opposite—that psychologists

and mental health professions ignore or disregard

clients’ desires as to their gender identity when

considering treatment options.

V. The Sixth Circuit Relied on Misleading and

Unfounded Narratives that Create a Distorted

Perception of the Psychological and Medical

Support Necessary for Transgender Youth.

The Sixth Circuit’s decision characterized the use of

medications for pubertal suppression and/or hormone

therapy for treating transgender youth as harmful

primarily on the grounds that the “long-term harms of

these treatments, some potentially irreversible, remain

unknown and outweigh any near-term benefits because

the treatments are ‘experimental in nature and not

supported by high-quality, long-term medical studies.’”

Pet. App. 7a-8a. That statement, however, both ignores

the available scientific literature demonstrating the

safety and efficacy of these treatments and is premised

on a flawed understanding of pediatric medicine.

Clinical standards of care require that evidence

certainty and quality are appropriately weighted

against the balance of benefits and harms of denying

medical care, as well as the patient’s values and

Capacity, Rights, and Authority to Consent to Hormone Therapy,

18 J. Bioethical Inquiry 151 (2021); Natalie Holt et al., The

OftenǦCircuitous Path to Affirming Mental Health Care for

Transgender and GenderǦDiverse Adults, 25 Current Psychiatry

Reps. 105 (2023); Elana Redfield et al., Prohibiting GenderAffirming Medical Care for Youth, Williams Institute (Mar. 2023),

https://williamsinstitute.law.ucla.edu/wp-content/uploads/TransYouth-Health-Bans-Mar-2023.pdf.

preferences. The Sixth Circuit’s conclusion fails to

contextualize the available evidence within the context

of pediatric medicine, in which no other area of

pediatrics is held to the same standard of research

quality and certainty.76 In fact, “parallels between

gender-affirming medical care and other areas of

pediatrics are abundant.”77 As with other areas of

pediatric care, “careful use of the treatment options we

have now, with the best evidence we have, defines

pediatric care” treatment standards.78 And, as further

explained above, the available and widely accepted

medical evidence credibly indicates that medications for

pubertal suppression and/or hormone treatments

effectively treat gender dysphoria, that transgender

youth benefit from these treatments, and that the

continuation of these interventions into adulthood

improves medical and mental health outcomes.

Further, the Sixth Circuit’s decision fails to

contextualize its statement that standards of care for

minors “have become less restrictive over the course of

time so that fewer procedures require mental health

evaluation, fewer recommendation letters are required,

and more types of professionals are viewed as capable of

providing such evaluations.” Pet. App. 6a (internal

quotation omitted). It is important for the Court to

understand that the evolution of multidisciplinary care

for transgender youth, which is based on the

McNamara et al., supra note 52.

Id. at 14.

Id. at 15.

accumulation of data over time, is rooted in the evolution

of social attitudes towards transgender individuals.

“Historical approaches to care were situated in the

belief that transgender identities are pathological in

nature and associated with poor quality of life and

psychosocial outcomes, develop in response to

psychosocial factors, and are malleable in childhood.”79

Thus, previously, social and medical transition were

considered only after persistent attempts to change

transgender identity failed and patients reached

adulthood.

With increased understanding and

improvements in scientific studies and data, however,

standards of care have shifted over time. Accordingly,

over the last decade, there has been a significant shift in

pediatric transgender healthcare, with social and

medical interventions being widely adopted as the

appropriate standard of care. As discussed above, these

interventions are effective, evidence-based, and safe.

Coyne et al., supra note 10, at 482.

CONCLUSION

For the foregoing reasons, amici respectfully request

that this Court reverse the decision below.

September 3, 2024

Respectfully submitted,

DEANNE M. OTTAVIANO

AMERICAN PSYCHOLOGICAL

ASSOCIATION

750 First Street NE

Washington, DC 20002

(202) 336-6100

JESSICA RING AMUNSON

Counsel of Record

ILLYANA A. GREEN

JESSICA SAWADOGO

JENNER & BLOCK LLP

1099 New York Avenue NW

Suite 900

Washington, DC 20001

(202) 639-6000

jamunson@jenner.com

HOWARD S. SUSKIN

JENNER & BLOCK LLP

353 North Clark Street

Chicago, IL 60654

(312) 222-9350

Counsel for Amici Curiae

This is a copy of a public record, reproduced as it was published. It is not legal advice, and it may not be the version a court would rely on. Check the official source before you cite it.