Transgender youth often experience significant distress at the gap between their physical appearance and their gender identity, which can lead to high rates of substance abuse, self-harm, and suicidal ideation. The American Medical Association, the American Academy of Pediatrics, and other top medical groups have supported gender-affirming treatments like puberty blockers and hormone therapies to reduce those risks.

Justice Samuel Alito, the court's leading cultural conservative, disputed that medical consensus. He pointed to recent regulatory changes in the United Kingdom and some Scandinavian countries that limited access to treatments for minors, as well as an official report by a prominent British doctor that concluded the evidence for treatments like puberty blockers and hormone therapies was "remarkably weak." (Others have disputed those conclusions.)

At one point, he questioned whether the treatments would reduce the risk of suicide among transgender youth. "A lot of categorical statements have been made this morning in argument and in the briefs about medical questions that seem to me to be hotly disputed, and that's a bit distressing," Alito said. "One of them has to do with the risk of suicide. Do you maintain that the procedures and medications in question reduce the risk of suicide?"

"I do, Justice Alito, maintain that the medications in question reduce the risk of depression, anxiety, and suicidality, which are all indicators of potential suicide," Strangio replied. "Do you think that's clearly established? Do you think there's reason for disagreement about that?" Alito continued. When Alito pointed to the British report's finding that there was "no evidence that gender-affirmative treatments reduce suicide," Strangio noted that studies had found a reduction in suicidal ideation, and that completed suicides weren't measured by some of the report's cited studies.