North Dakota's Supreme Court Upholds the State's Ban on Gender-Affirming Care for Minors

The North Dakota Supreme Court ruled unanimously on Thursday that the state’s 2023 ban on gender-affirming care for minors is constitutional, closing off what had been the last live challenge to the law in North Dakota’s own courts.

The decision affirms a district court judgment from October 2025 and leaves House Bill 1254 fully in force. Under the law, prescribing puberty blockers or hormone therapy to a minor for the purpose of gender transition is a crime, with penalties ranging from misdemeanours to felonies; transition-related surgery for minors is also prohibited.

What the court decided

Writing for the court, Justice Douglas Bahr held that “minors do not have a fundamental right under Article I, § 1 of the North Dakota Constitution to a particular course of medical treatment.” The justices further concluded that the statute does not discriminate on the basis of sex or transgender status, and that transgender people do not constitute a group entitled to heightened constitutional protection under state law.

That combination is decisive in practice. When a court finds that no fundamental right and no protected class is involved, it applies the most deferential standard of review available — and legislatures almost always survive it. The court said as much, framing the dispute as one for lawmakers rather than judges. “The forum for Dr. Casas’s factual arguments regarding the safety and effectiveness of gender-affirming treatment is the Legislature, not this court,” the opinion reads, according to the North Dakota Monitor, which has followed the case closely.

Justice Mark Friese recused; Northeast Judicial District Judge Michael Hurly sat in his place. The court heard oral arguments in late June.

Who brought the case

The suit was filed in 2023 by three families with transgender children, together with Dr. Luis Casas, a North Dakota pediatric endocrinologist. District Judge Jackson Lofgren later dismissed the families from the case for lack of standing, leaving Casas as the sole plaintiff — a procedural turn worth noting, because it meant the appeal was argued as a doctor’s claim about the practice of medicine rather than as a family’s claim about raising a child.

Casas is represented by Gender Justice, the legal organisation that has handled the litigation from the start. His response to the ruling was pointed. “This ruling means the government still stands between me and my patients,” he said in a statement. “Families I’ve worked with for years are being forced into an impossible choice: uproot their lives and leave the state, or go without the care their doctors recommend and their kids need.”

At trial before Lofgren — a seven-day proceeding in early 2025 that included testimony from doctors, from two transgender teenagers and from their parents — Casas’s lawyers argued that the ban singles out one diagnosis for prohibition while leaving the same medications available to other adolescents for other conditions. His attorney Tanya Pellegrini called it “completely unprecedented” for lawmakers “to single out a population from being able to receive medical care, categorically ban their medical treatment, and override parental consent.”

Solicitor General Phil Axt, defending the law, characterised gender dysphoria as a mental health condition and argued that North Dakota courts have never recognised a right to obtain mental health care, and that the state may regulate a treatment whose safety remains contested. Attorney General Drew Wrigley called the ruling “common sense” and said it was “firmly grounded in our constitution and our shared history.”

Why this is not simply Skrmetti again

It would be easy — and wrong — to file Thursday’s decision as an aftershock of United States v. Skrmetti, the 2025 US Supreme Court ruling that upheld Tennessee’s ban on gender-affirming care for minors. The two rulings point the same direction, but they answer different questions.

Skrmetti concerned the federal Equal Protection Clause: whether the US Constitution permits a state to enact such a ban. Thursday’s case concerned Article I of the North Dakota Constitution: whether that document permits it. Those are genuinely distinct inquiries, and state constitutions are not obliged to stop where the federal one does. They frequently go further. The clearest recent illustration is Montana, where the state Supreme Court in December 2024 upheld an injunction blocking that state’s ban, relying on Montana’s unusually explicit constitutional right to privacy — a protection with no direct federal analogue.

So a state constitutional claim was, in principle, a real second chance. North Dakota’s justices simply declined to find in their own constitution the protections Montana’s found in theirs. Bahr noted in the opinion that other state and federal appellate courts have reached the same conclusion about comparable laws.

That divergence is now the shape of the American map: the same treatment, for the same patients, legal or criminal depending on which state line a family happens to live behind, in a country where roughly half the states now restrict this care in some form.

What happens next

For families in North Dakota, the practical answer is unchanged and unwelcome: care must be sought out of state, with the cost, travel and disruption that implies, or forgone. Gender Justice described the law as government overreach and has not indicated that the litigation is finished, though avenues within North Dakota’s own courts are now largely exhausted.

The more durable point is that the argument has been handed back to the legislature, which is exactly where the court said it belongs. North Dakota lawmakers passed HB 1254 in 2023; they can repeal or amend it. That is a slower road than litigation and, on current numbers, an unlikely one. But it is the road the court has now made the only one — and it is the reason the organisations working in the state have spent this year building toward legislative sessions rather than courtroom dates.