In Bismarck, North Dakota, a pivotal legal battle over transgender health care is set to unfold in state district court, beginning Monday, January 27. The eight-day bench trial will determine whether a law banning gender-affirming medical treatments for minors violates the North Dakota Constitution. The case comes more than a year after families of transgender youth and a pediatric endocrinologist challenged the statute, arguing that it unfairly targets trans children and strips them of necessary, evidence-based care.
A Controversial Law Under the Spotlight
House Bill 1254 (HB 1254)—signed into law in April 2023 by then-Governor Doug Burgum—criminalizes providing hormone therapy or puberty blockers to anyone under the age of 18 if the purpose is to assist with a gender transition. Doctors who prescribe such treatments face charges of a Class A misdemeanor, which carries up to 360 days in jail and $3,000 in fines. The law also classifies transition-related surgical procedures for minors as a Class B felony, punishable by up to 10 years in prison and a $20,000 fine.
Proponents of HB 1254, including Republican Rep. Bill Tveit, who sponsored the legislation, claim the law shields children from treatments that they believe could be irreversible. Tveit has argued that if teens later “change their minds,” permanent interventions may have profound health and psychological consequences. According to him, waiting until an individual is of legal adult age offers better protection from potential regrets.
Critics, including major medical associations such as the American Academy of Pediatrics and the American Medical Association, strongly disagree. They say gender-affirming treatments—carefully administered under established medical guidelines—improve quality of life for transgender youth and reduce risks of depression, anxiety, and self-harm. According to Brittany Stewart, senior staff attorney at the nonprofit Gender Justice and lead counsel for the plaintiffs, the law’s blanket ban “is actively harming children” by cutting off recognized and necessary care.
From Family Lawsuit to Single-Plaintiff Case
When the lawsuit was originally filed in late 2023, it included three families of transgender minors alongside a pediatric endocrinologist, Dr. Luis Casas. They asserted that by criminalizing recognized medical treatments exclusively for transgender youth, HB 1254 violates several constitutional rights, including equal protection and parental autonomy.
However, a series of preliminary rulings significantly narrowed the lawsuit. The judge dismissed the families’ claims after determining that their children fell under the law’s exemption for minors who had already begun receiving gender-affirming treatments before the ban took effect. Since their care remained technically available, the court ruled these families lacked “standing” to challenge the statute.
With the families removed, only Dr. Casas continues as a plaintiff. He argues that new transgender and nonbinary patients now face legal barriers to starting hormone therapy or puberty blockers, placing them at risk of grave mental health consequences and denying them the medically accepted standard of care. Despite the families’ dismissal from the case, they are expected to testify as witnesses, describing the confusion, stress, and fear they experienced under the ban.
Medical Consensus and Mental Health
The medical community broadly supports gender-affirming care as an effective, evidence-based approach to treating gender dysphoria, defined as significant discomfort or distress arising from a mismatch between one’s gender identity and assigned sex at birth. In North Dakota specifically, pediatric endocrinologists—like Dr. Casas—note that transgender youth face disproportionately high levels of bullying and discrimination. A 2022 survey by the U.S. Centers for Disease Control and Prevention found that one in four transgender teens reported attempting suicide in the past year, a stark contrast to their cisgender peers.
Restrictions on health care only exacerbate these numbers, according to Stewart and other experts. They emphasize that puberty blockers and hormone therapy are administered carefully, involving multiple steps of consultation, psychological evaluation, and parental approval. “When you ban the only medically supported care for a specific condition—and only for young people under 18—you’re not protecting those kids,” Stewart said. “You’re actively harming them.”
Crossing State Lines for Care
Although HB 1254 contains an exemption for minors who started treatments prior to April 2023, many medical providers fear that vague language in the law puts their professional licenses—and potentially their freedom—at risk. This legal uncertainty has reportedly forced some families to travel out of state for appointments. One family, Stewart noted, undertakes an eight-hour round trip to maintain care already in progress, losing school days and income in the process.
For families who were in the early stages of exploring hormone therapy or puberty blockers but had not yet begun treatment, the ban has left them with few options. “Families face the heartbreaking choice of uprooting their lives or denying their child treatment that medical experts agree is essential for their well-being,” said Stewart.
Legal Precedent and Nationwide Context
North Dakota’s gender-affirming care ban aligns with a wave of similar legislation enacted in more than two dozen states. Federal courts have struck down bans in Arkansas and Florida, ruling such laws unconstitutional—though Florida’s ruling is temporarily on hold pending appeal. In neighboring Montana, a state court has also issued a temporary injunction, halting that state’s ban from taking effect.
With Dr. Casas’s trial moving forward, North Dakota joins this national legal conversation on the rights of transgender children. Advocates see this case as especially critical because it revolves around protections within the state constitution, which sometimes provide stronger or more specific safeguards than the U.S. Constitution. A favorable ruling for Dr. Casas could resonate beyond the Peace Garden State, potentially influencing other jurisdictions where families and doctors are fighting comparable bans.
The Bottom Line
The bench trial is expected to span eight days, featuring testimony from medical experts, policy analysts, and the remaining plaintiff, Dr. Casas. Since there is no jury, the presiding judge will issue the verdict. A ruling could take weeks or even months after the trial concludes.
If the court finds the ban unconstitutional, the state may be prohibited from enforcing HB 1254. That decision would effectively restore the option of gender-affirming care for new patients who arrive in clinics across North Dakota. On the other hand, if the state prevails, families of transgender youth will likely be forced to continue searching for care elsewhere—or go without it altogether.
In the meantime, transgender people, their loved ones, and a growing network of allies are watching closely. Many see the trial not just as a referendum on a single law but as a broader statement on whether trans youth have the same right to exist and thrive as any other child. For those directly affected by HB 1254, the stakes are deeply personal. As court proceedings begin, the community stands united in the hope that science, empathy, and a commitment to children’s well-being will guide the court’s decision.
