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During oral arguments before the Supreme Court last week in U.S. v. Skrmetti, it became clear that the dispute is over more than just gender medicine — it’s about a realignment of medicine’s purpose. The case examines the constitutionality of Tennessee’s law banning gender-affirming treatments for minors. The prosecution claims such treatments are medically necessary, and banning them constitutes sex discrimination against children seeking such treatments to align their bodies more closely to their chosen gender.

Medical necessity has traditionally meant targeting disease processes to achieve physiological health. Transgender treatments such as hormones instead disrupt physiological health to achieve a body that aligns with a patient’s mental state. This new direction mandates that doctors adjust their risk assessment to accept iatrogenic side effects as a necessary cost of treating patients. This is in stark contrast to the traditional “do no harm” approach that doctors are bound to by oath, cracking medicine’s foundational integrity.

Justice Sonia Sotomayor suggested an acceptance of potential harms from gender-affirming treatments by interjecting the Tennessee solicitor general’s discussion of the risks with, “Every medical treatment has a risk, even taking aspirin.”

Aspirin can be dangerous when taken inappropriately or by those with an allergy, but the risks and benefits have been studied since the 1800s. Aspirin aligns a diseased body with a healthier physiology through the reduction of inflammation, while its anti-platelet activity lessens the formation of harmful blood clots. Patients prescribed aspirin have been diagnosed with a condition necessitating its functions.

Conversely, so-called “gender-affirming” treatments have no long-term studies that establish a clear risk-benefit ratio. The evidence so far from multiple systematic reviews does not demonstrate a reduction in suicide — a claim used to promote these treatments. Unlike aspirin, which is used to correct a diseased physiology, gender-affirming treatments seek to disrupt a healthy physiology through hormones and surgeries, thereby introducing hazards like cancer, diminished cardiovascular health, and infertility. The “pause” button described by the U.S. solicitor general in reference to puberty blockers has been shown to decrease bone density and cognition.

Since it is impossible to diagnose which children will persist with a transgender identity into adulthood, misdiagnosis is a significant concern. Most children who experience natural puberty will outgrow the distress about their bodies, with many discovering they identify as non-heterosexual.

Detransitioners who have received irreversible “gender-affirming” treatments only to realize they were never transgender represent the unmitigable risk of misdiagnosis. Hippocratic oath medicine doesn’t allow this harm to be whitewashed under the premise that it is, as the ACLU attorney indicated, a “very low” “one percent.”

The Joint Commission, an organization that advocates for safety in health care, launched an effort to reduce the harm from wrong-site surgeries (when a wrong limb or organ is removed) after 615 reports in a twelve-year period. Estimating 6.5 million surgeries annually, that’s a harm rate of 0.00000788 percent — too high for doctors seeking to “first, do no harm.”

The truth is, the stated “one percent” risk of regret is unverifiable. The rate of detransition is unknown because there is no system in place to measure it. While diagnosis codes exist to document clinical encounters related to gender dysphoria and “sex-reassignment” surgery (as the CDC labels it), making them traceable for research purposes, none exist to document, tabulate, and study detransitioning. And most patients who detransition don’t report it to their gender clinician.

Justice Ketanji Brown Jackson exposed a misunderstanding of how clinicians treat patients by arguing that patients of a certain sex who don’t receive the same treatments as the opposite sex are experiencing sex-based discrimination.

Sex often determines what treatments are medically safe and necessary. For example, women who have had their diseased ovaries removed require a dose of estrogen that is less than that prescribed to a man seeking to develop physical female characteristics. The woman receiving the lower dose of estrogen is not experiencing discrimination, but rather the appropriate amount of hormone to best achieve a healthy female physiology. Similarly, it is not discriminatory to withhold treatment with tamsulosin for an enlarged prostate from a woman who has no prostate. But if she had an obstructing kidney stone, she may receive tamsulosin for a medical reason — to help improve urinary flow.

The justices have months to ponder their decision. It remains to be seen if medicine will continue to operate within the boundaries of healing disease under an oath to “first, do not harm,” or be pushed into unchartered territory that dismisses the potential of causing disease in an effort to heal the psyche of gender-distressed children.

Dr. Aida Cerundolo is a board-certified emergency medicine physician. She received is a graduate of the University of Massachusetts Medical School and completed her Emergency Medicine residency at the University of Massachusetts Medical Center. She has been practicing clinical emergency medicine for over twenty years.