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In this piece, Joseph Figliolia unpacks the Supreme Court’s recent decision to strike down a Colorado ban on certain kinds of therapy for patients with gender dysphoria. While the decision does not resolve the debate entirely, Figliolia stresses its importance, noting that it revived an important debate in the medical community and clears the way for real progress.
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Last month, the Supreme Court struck down Colorado’s ban on so-called “conversion therapy” for patients with gender confusion.
The 8-1 decision on Chiles v. Salazar is not just consequential for constitutional law but for the future of gender medicine. In striking down Colorado’s law, the Court ruling put a stop to a dangerous regime of viewpoint-based censorship in medicine. The decision raises serious constitutional questions for similar laws on the books in 22 other states.
The suit was brought by a licensed mental health counselor, Kaley Chiles, who was prevented from talking with clients in ways that could help them reconcile their mind and body. Instead, the state insisted she unambiguously affirm and facilitate “gender transitions.”
Lower courts accepted the argument that these laws merely regulate professional conduct, subject only to minimal constitutional scrutiny. The Supreme Court rejected that logic. When the state restricts what a therapist can say based on the viewpoint expressed, it triggers the highest level of First Amendment protection.
Justice Ketanji Brown Jackson’s lone dissent reflects the prevailing view within much of the medical establishment: that “conversion” practices are inherently harmful, and that gender identity exists as a fixed and natural category within the spectrum of human diversity. But this position rests on contested assumptions about the evidence base and about the nature of gender identity itself.
Much of the research cited to justify these bans focuses on sexual orientation change efforts in adults, not therapeutic approaches addressing gender dysphoria in minors. In recent years, advocacy groups and professional associations have expanded the definition of “conversion therapy” to include nearly any attempt to explore or resolve gender-related distress without immediate affirmation — collapsing fundamentally different clinical questions into a single prohibited category.
Yet gender dysphoria in youth is not diagnostically stable. Researchers have found that many children who experience early dysphoria grow out of it by the end of puberty.
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At the same time, the number of young people identifying as transgender has risen dramatically in recent years. Using CDC data, the psychologist Jean Twenge estimated that trans-identification increased 422% among 18–24-year-olds between 2014 and 2023, notably with no corresponding increase among adults older than 35. This suggests that trans-identification’s “concept creep” is trickling down into young people’s self-concepts and uniting otherwise distinct clinical populations under a single “transgender” umbrella.
None of this proves that any single therapeutic approach is correct. But it does underscore the need for open clinical inquiry — not legal mandates that enforce one model while prohibiting others.
An affirmation-only approach risks flattening complex psychological and developmental factors into a single predetermined outcome. Such adherence to ideological conformity has gotten us a list of malpractice suits and the recent landmark $2 million payout to Fox Varian, who underwent a double mastectomy at sixteen despite a complex and troubling psychiatric and family history.
This should not come as a surprise. Many patients presenting with gender-related distress also experience significant psychiatric comorbidities, and their cases often require careful, individualized assessment.
As a Department of Health and Human Services report on pediatric gender dysphoria convincingly argues, psychotherapy is preferred as a first-line treatment for gender dysphoria because it possesses a more favorable risk-benefit ratio than medical interventions, which have only “low certainty” evidence for benefit according to evidence reviews. This view is supported by a nationwide cohort study of Finland, which found patient populations after 2010 displayed more complex psychiatric needs both before and after clinic referral — many of which were not resolved by medical transition.
Clinicians should be free to explore these various treatment options with their patients. Yet laws like Colorado’s effectively prohibit that exploration, enforcing an ideological boundary around acceptable care.
The Supreme Court’s decision in Chiles does not resolve the broader medical debate. But it does something equally important: it reopens the space for that debate to occur.
If mental health care is to remain grounded in evidence, ethics, and individualized treatment, it cannot be governed by laws that dictate conclusions in advance. The Court has recognized that when the state mandates one viewpoint while silencing others, it is no longer regulating medicine — it is enforcing orthodoxy.
That is a dangerous precedent. And, at least for now, one the Constitution still forbids.
Joseph Figliolia is a policy analyst at the Manhattan Institute.
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