When Tennessee banned gender-affirming care for transgender youth last year, Sarah began taking days off work to drive hundreds of miles from her home in Nashville to a North Carolina clinic that could treat her transgender son.

But just a month later, a similar ban went into effect in North Carolina, sending Sarah into a panic as she realized the closest state where she could take her son would be Ohio – more than 400 miles away. To her relief, the North Carolina law made exceptions for children who were already receiving treatment.

“I should just be able to go five minutes down the road and have my child taken care of and medication easily received and not have to have a 12-hour trip,” Sarah told CNN, using a pseudonym out of concern for her family’s safety.

Parents like Sarah and transgender communities across the United States will be paying close attention Wednesday as the US Supreme Court hears arguments in US v. Skrmetti – a case that could determine whether states can ban certain forms of gender-affirming care for trans children and teens.

The case, brought by the Biden administration on behalf of families of trans youth, challenges the constitutionality of Tennessee’s gender-affirming care ban, which restricts puberty blockers and hormone therapy for transgender minors and enacts civil penalties for doctors who violate the law.

Tennessee Attorney General Jonathan Skrmetti argued in court documents the law ensures “minors do not receive these treatments until they can fully understand the lifelong consequences or until the science is developed to the point that Tennessee might take a different view of their efficacy.” Attorneys for the plaintiffs, however, point to major medical organizations that have said the treatments are safe and may be medically necessary.

Since the state law was enacted last year, parents like Sarah have gone to extraordinary lengths to seek out-of-state treatment for their trans children. Some have told CNN they are dipping into their life savings and taking on debt so they can afford the costly travel.

The direction and scope of the court’s decision would be pivotal for both sides and felt by transgender communities nationwide. A win for the plaintiffs could signal that trans people are protected from discrimination under the Constitution’s equal protection clause and bolster efforts to fight anti-trans laws that have swept the nation in recent years.

But a win for the state could advance efforts by Republicans, including President-elect Donald Trump, and other conservative groups that vowed to restrict how trans people can access health care and perform other everyday tasks in ways that align with their gender identity, including playing sports and using the restroom.

As the parties present their oral arguments on Wednesday and wait for the court’s ruling to be handed down next year, here’s how the decision could affect trans communities:

What could happen if the ban is struck down

If the court rules the Tennessee ban is unconstitutional, it will deliver a resounding win for transgender rights advocates. Similar state laws would be effectively invalidated, and trans youth would gain greater protections in accessing gender-affirming care, legal experts say.

“That would be a monumental achievement for the trans legal movement, and it remains a distinct possibility,” said Kate Redburn, co-director of Columbia Law School’s Center for Gender and Sexuality Law.

For the children and teens who have been unable to get care to treat their gender dysphoria – the mental distress a person feels when they feel their sex assigned at birth doesn’t align with their gender identity – being able to access this health care could have a transformative effect, said Dr. Maurice Garcia, director of the Cedars-Sinai Transgender Surgery and Health Program.

“Gender dysphoria is an enormous distraction from life. It’s a barrier to living life in a normal, full way, where you enjoy your day, you enjoy going out with friends, you enjoy being in public,” Garcia said.

Gender-affirming care, which for youth may include puberty suppression or hormone therapy, helps transgender people live in accordance with their gender identity. Access to these treatments can help ease anxiety and depression, which occur at high rates among transgender youth – largely because of stigma and social isolation, Garcia said.

Currently, 26 states across the US have passed laws restricting gender-affirming care for trans youth, though bans in Montana and Arkansas have been temporarily blocked, a CNN analysis of data from the Movement Advancement Project shows. The Williams Institute, a public policy think tank at the University of California Los Angeles, estimates more than 110,000 teens live in the states where bans are in effect.

The court’s decision would undermine only bans that are structured similarly to Tennessee’s – in a way that trans rights advocates say discriminates between trans and cisgender children – meaning some state bans could remain in effect, said Redburn.

It’s also possible the Supreme Court could send the case back to the appeals court to consider Tennessee’s law with “heightened scrutiny” – a higher legal standard than the appeals court used last year when it upheld the ban. Applying heightened scrutiny to gender-affirming care restrictions would require states to show they have an important government interest that is “substantially related” to banning the treatments.

Lawyers for the Biden administration, who have argued the Tennessee ban would not pass this stricter standard for review, have suggested the justices could consider whether the law passes constitutional muster under heightened scrutiny instead of leaving it to the lower court.

Sarah, the mother in Tennessee, said the stakes for receiving hormone therapy could not be higher for her child. Before receiving the treatment, she says, her son became withdrawn and increasingly frustrated as puberty transformed his body in ways he hated. By the time he was 15, he had attempted suicide three times, she said. But since undergoing testosterone therapy, her son feels confident, outgoing and more at peace with himself.

“I had friends of ours come up and tell me how much they could see that difference and the light in his eyes,” Sarah said. “Within a few months (of receiving hormone therapy) it was just a huge change. It was amazing.”

But a ruling in favor of the plaintiffs would not be the end of the fight over health care access for trans communities, said Elana Redfield, federal policy director at the Williams Institute.

“I think we’d expect to see states continue to innovate ways to ban access to gender affirming care,” said Redfield, who co-wrote a brief to the court in support of the plaintiffs.

Redfield pointed to Arkansas, where the state’s ban on gender-affirming care has been blocked by a judge. Even so, Republican lawmakers passed another law last year that allows patients who received gender-affirming care as minors to file a malpractice lawsuit against their doctor for up to 20 years after they turn 18 – a far longer period than is typically allowed for medical injury claims. The law, which she called a “backdoor ban,” would make it very difficult for physicians to get malpractice insurance coverage and effectively disincentivizes doctors from providing the treatment.

What could happen if the ban is upheld

A court ruling that upholds the Tennessee law would bolster the national patchwork of trans health care bans, making gender-affirming care for minors much more difficult to access in half of the country and potentially opening the door for wider restrictions for trans people, Redburn said.

Transgender advocates fear the lack of health care access could exacerbate mental illness among trans minors and, in extreme cases, push some families to leave the state entirely.

In general, transgender youth grapple with significant mental health issues, research shows. A 2018 study found trans youth reported mental health problems at rates sevenfold higher than their cisgender peers. About half of transgender and nonbinary youth in the US reported considering suicide, and 14% made an attempt, according to a 2024 survey.

“Untreated gender dysphoria can be all-consuming,” said Shawn Meerkamper, a managing attorney at the Transgender Law Center.

In a brief written to the court, Meerkamper and other LGBTQ advocates argued that lack of access to gender-affirming care has caused some trans youth “extreme distress, including severe anxiety and depression, substance issues, self-harm, and/or suicidality.”

As families in states with trans health care bans grow increasingly desperate, Meerkamper said he has seen people split up their household, sending one parent to live in another state with their trans child while the other parent and siblings stay behind because of work and school obligations.

Nearly half, or 45%, of transgender and nonbinary people surveyed by the Trevor Project, an LGBTQ advocacy group, said they or their family have considered moving to a different state because of “LGBTQ+-related politics and laws.”

Sarah has already explored what it would take to uproot her family to a state where her trans son could receive treatment. “I will do whatever will keep us safe and him happy,” she said.

By ruling that Tennessee is not discriminating against trans youth based on their sex, and therefore are not shielded by the equal protection clause, the court could provide a green light for conservative lawmakers to extend their health care restrictions to trans adults, according to Redburn.

Lawyers for the plaintiffs also argue that the decision could have implications for Americans writ-large, providing a “stepping stone towards further limiting access to abortion, IVF, and birth control.”

They point to the possibility that the court could apply part of its decision in Dobbs v. Jackson, which allowed states to ban abortion. In a short aside in his Dobbs decision, Justice Samuel Alito wrote that abortion regulations do not discriminate based on sex and would not require heightened scrutiny – the stricter standard used to determine the constitutionality of laws that classify individuals based on certain characteristics.

Tennessee has relied heavily on this argument while defending its gender-affirming care ban. The state argues its law equally applies to both trans girls and trans boys and should be considered a regulation of medical care.

Such medical regulations for minors is an issue that should be left to elected officials, the state argues.

“Nothing in the Constitution deputizes Petitioners to override the legislature’s judgment and demand a policy they believe to be more favorable,” Tennessee officials wrote in a court brief.

But attorneys for the plaintiffs argue the law clearly discriminates based on sex because it does not apply to cisgender children. For example, a doctor could prescribe puberty blockers to a cisgender child undergoing puberty too soon but could not prescribe the same medication to a trans child to prevent them from undergoing puberty in a way that would exacerbate their gender dysphoria.

No matter the outcome of Skrmetti, Meerkamper said, transgender communities would still have other legal avenues to fight laws restricting trans rights, as several district courts are considering challenges to anti-trans laws.

“We’re always going to be here, and we’ve always been fighting and surviving because we’ve always had to, and that’ll be true no matter what happens at the Supreme Court,” he said.