U.S. Said To Lack Evidence For Guidelines On Gender-Affirming Care For Minors
In a U.S. Supreme Court filing, the state of Alabama calls the federal government's decision to provide gender-affirming care to minors a "medical, legal, and political scandal"
Note: In United States v. Skrmetti (2025), the U.S. Supreme Court ruled 6-3 on June 18, 2025, that Tennessee’s Senate Bill 1 (SB1)—which bans puberty blockers and cross-sex hormones for minors when used to treat gender dysphoria or enable identification with a gender inconsistent with biological sex—does not violate the Equal Protection Clause of the Fourteenth Amendment.
If the state of Alabama is correct, it very well could be a scandal of immense proportions.
Alabama Attorney General Steve Marshall submitted an amicus brief on Tuesday asserting there was never any real evidence to justify the Biden Administration’s decision to offer gender confused minors medical interventions that included surgeries (ex. vaginoplasties), puberty blockers, and hormones that carry risk of infertility.
After two years, the U.S. did an about-face last summer and banned gender-affirming surgery for minors, but minors can still receive chemical treatments.
Marshall filed the brief in a U.S. Supreme Court case, United States v. Skrmetti, brought by the Biden administration challenging a Tennessee law that ban gender-affirming care for minors.
Marshall says the U.S. Dept. of Health and Human Services (HHS) challenged the Tennessee law, rather than a similar Alabama law, because the Alabama case was farther along and the HHS hoped to block discovery in the Tennessee case.
According to Marshall, the Biden Administration knew there was a lack of evidence to support gender-affirming care but proceeded anyway for political reasons.
“The federal government, ‘social justice lawyers’ from prominent activist organizations, and self-appointed experts at the World Professional Association for Transgender Health (WPATH) conspired to abolish age limits for sterilizing chemical treatments and surgeries,” Marshall writes in the brief.
Marshall says WPATH hired Johns Hopkins University to review evidence on altering children’s bodies to address gender confusion but the team "found little to no evidence about children and adolescents.” He alleges that information, which was shared with the U.S. government, was suppressed by WPATH.
WPATH made a decision not to conduct a systematic review before making treatment recommendations because “evidence-based review reveals little or no evidence and puts us in an untenable position in terms of affecting policy of winning lawsuits,” said Marshall.
When shown the WPATH guidelines, Marshall says Admiral Rachel Levine, the Assistant Secretary for Health at the U.S. Department of Health and Human Services, allegedly “demanded that WPATH remove from the guideline all age limits for chemical treatments, chest surgeries, and even surgeries to remove children’s genitals.” WPATH is said to have obliged and changed its medical guidelines to suit U.S. political considerations.
Levine is a man who became transgender and now identifies as female.
Marshall said that WPATH consulted attorneys from “activist” agencies to craft the WPATH Standards of Care 8 (SOC-8) to avoid legal challenges. These agencies include the ACLU, Lambda Legal, GLAD, and the Transgender Legal Defense & Education Fund. The SOC-8 guidelines were published in 2022.
Alabama notes that WPATH’s strategy initially was successful - courts enjoined Tennessee and Alabama from enforcing their bans on gender-affirming care for minors. Those decisions were eventually overturned on appeal, which created a conflict in the circuits, leading to the current U.S. Supreme Court review.
In the brief, Marshall states the British National Health System conducted a systemic review that found insufficient evidence to warrant gender-affirming care. The so-called Cass Review concluded that guidelines that recommended sex-change procedures for minors “flunked the ‘bedrock’ criterion of development rigor.”
Dr. Hillary Cass, who was in charge of the review, described gender-affirming care as the only “area of pediatric care where we give young people a potentially irreversible treatment and have no idea what happens to them in adulthood.”
Tennessee’s 2023 law bars gender-affirming care, such as hormone treatments and gender-transition surgeries, for transgender patients under 18. Health-care providers may continue to administer hormone therapy to patients who were already receiving it until March 31, 2024.
The plantiffs in the Tennessee lawsuit are a 16-year-old transgender girl who has received puberty blockers and estrogen therapy, a 13-year-old transgender boy who has received puberty blockers, and a 16-year-old transgender boy who has received puberty blockers and testosterone therapy.
The Biden administrative intervened under a federal law that allows the govenrment to intervene in private cases if the Attorney General certifies the case is of “general public importance.”