Federal appeals court endorses Arkansas ban on gender-affirming care for minors

On Tuesday, the full U.S. Court of Appeals for the Eighth Circuit upheld Arkansas’s ban on gender-affirming care for minors.

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The 35-page, 8–2 ruling marks the first time a full federal appellate court has weighed in on such a law since the U.S. Supreme Court’s June decision in United States v. Skrmetti, which upheld Tennessee’s nearly identical ban. Together, the two rulings cement a new constitutional framework that allows states to regulate, and in many cases, prohibit treatments that every major U.S. medical association, including the American Academy of Pediatrics and the Endocrine Society, considers essential for the health and well-being of transgender youth.

Related: Citing Skrmetti, appeals court rejects challenge to Oklahoma ban on gender-affirming care for youth

Arkansas’s 2021 Save Adolescents from Experimentation Act is among the most restrictive in the country. It forbids physicians from prescribing puberty blockers, providing hormone therapy, or performing surgeries to facilitate a gender transition for anyone under 18. It also bars formal referrals for such care, creating professional risks for providers and severing a critical link between families and affirming medical guidance.

Writing for the majority, Judge Duane Benton, a George W. Bush appointee, concluded that the SAFE Act regulates medical procedures and age categories rather than classifications based on sex or transgender status. Under that interpretation, the law is judged by the most deferential constitutional standard, rational basis review, and need only be reasonably related to a legitimate state interest. The court found Arkansas lawmakers could plausibly view the restrictions as protective of minors, despite the absence of evidence in the medical community on that point.

Related: Supreme Court rules states can ban gender-affirming care for youth in U.S. v. Skrmetti

The decision aligns with Skrmetti, in which Chief Justice John Roberts reasoned that such bans address treatments rather than identities.

For constitutional law professor Leah Litman, that framing is both legally flawed and dangerous. Litman told The Advocate after the Skrmetti ruling that the logic collapses under scrutiny: the very same treatments remain legal for cisgender minors with other conditions, such as precocious puberty, but are banned when prescribed for gender dysphoria. “That’s obviously discrimination on the basis of gender identity,” she said. Litman warned that Skrmetti “opens it up to states saying that adults can also not receive this care,” setting the stage for far broader restrictions.

Of the seven states in the circuit, six are Republican-controlled and have passed laws restricting or banning gender-affirming care for minors:

Arkansas, Iowa, Missouri, Nebraska, North Dakota, and South Dakota. Minnesota, the only blue state led by former Vice President Kamala Harris’s 2024 running mate, Gov. Tim Walz, has positioned itself as a “trans refuge” state.

Related: SCOTUS trans care ruling opens harmful loophole to take access from all trans people, says Leah Litman

Judge Jane Kelly, an Obama appointee, dissented in part, warning that the majority’s reasoning sidesteps the evidentiary record. She emphasized that the state had produced scant proof that the SAFE Act achieves its stated goals, a gap she believed warranted further scrutiny. Judge James Loken, appointed by George H.W. Bush, joined her opinion in full.

The Eighth Circuit’s decision comes just days after the U.S. Court of Appeals for the 10th Circuit cited Skrmetti in upholding Oklahoma’s 2023 ban on gender-affirming care for transgender youth. In that case, the appeals court affirmed a lower court’s refusal to block enforcement, noting that Skrmetti had already resolved key constitutional questions in favor of states.

“This is a tragically unjust result for transgender Arkansans, their doctors, and their families,” said Holly Dickson, executive director of the American Civil Liberties Union of Arkansas. “The state had every opportunity and failed at every turn to prove that this law helps children; in fact, this is a dangerous law that harms children."

Dickson added, “As we and our clients consider our next steps, we want transgender Arkansans to know they are far from alone and we remain as determined as ever to secure their right to safety, dignity, and equal access to the health care they need.”