The North Dakota Supreme Court has upheld the state’s 2023 restrictions on gender-affirming medical treatment for minors, affirming a district court judgment and leaving the law’s medication and surgery provisions in effect.
The appeal was brought by Dr. Luis Casas, a pediatric and adult endocrinologist, on behalf of himself and minor patients. In its Sept. 17 ruling, the court concluded that minors do not have a fundamental right under Article I, Section 1 of the North Dakota Constitution to a particular course of medical treatment. That conclusion determined the level of constitutional scrutiny applied to the law.
Justice Douglas Bahr, writing for the majority, said the statute does not discriminate on the basis of sex or transgender status because it bars the covered treatments for the same purpose regardless of a minor’s sex. Applying rational-basis review, the court held that lawmakers could reasonably conclude the restrictions advance the state’s interest in protecting minors’ health and welfare amid continuing debate about long-term risks and benefits.
Justice Jerod Tufte filed a special concurrence joined by Chief Justice Jon Jensen. The concurrence agreed with the result under current precedent while discussing the history of North Dakota’s constitutional privileges-and-immunities provisions and the parties’ proposed analytical frameworks.
The Legislature passed House Bill 1254 as an emergency measure in 2023. The official bill record says the act created a new criminal-code chapter prohibiting specified practices involving minors and providing penalties; Gov. Doug Burgum signed it, and it was filed with the secretary of state on April 21, 2023.
The law makes providing hormone treatment or puberty-blocking medication for the prohibited purpose a misdemeanor and certain surgeries a felony. It includes an exception allowing minors who began covered treatment before the effective date to continue under specified conditions. The Supreme Court ruling preserves that grandfather provision, so the judgment does not end every preexisting course of care.
The case reached the high court after a district judge upheld the law in 2025. An earlier account of that decision noted that North Dakota was among more than two dozen states with similar restrictions and that legal challenges across the country had produced differing outcomes before the U.S. Supreme Court permitted states to enforce such bans.
Practically, North Dakota clinicians remain subject to the statute’s licensing and criminal consequences when treating minors who do not qualify for its exception. Families seeking care must distinguish between patients protected by the pre-April 2023 grandfather clause and those barred from starting treatment under the law.
The decision resolves this state constitutional challenge at North Dakota’s highest court. It does not settle medical disagreement over the treatments, and the majority’s reasoning rests on a deferential legal standard rather than a judicial finding that every policy judgment in the statute is medically correct. Any further change would have to come through federal litigation, new legislation or a future constitutional theory not resolved in this appeal.
