The Supreme Court’s ruling last week in a challenge to Colorado’s ban on conversion therapy has raised questions about clinical practice there and in the nearly two dozen other states with similar laws. But legal experts say the decision changes less than initial reports suggested.

The 8-1 ruling in Chiles v. Salazar, issued Tuesday, March 31, did not strike down Colorado’s law banning conversion therapy for minors. Instead, the Court sent the case back to a lower court for another review, said Kara Ingelhart, JD, clinical assistant professor of law and director of the LGBTQI+ Rights Clinic at Northwestern Pritzker School of Law, Chicago.

“Colorado’s law is still valid with regard to all conversion therapy,” Ingelhart told Medscape Medical News. “All the states that currently have bans on conversion therapy can absolutely still enforce them, even with regard to talk therapy.”

But that may change in the future, Ingelhart noted. Here’s what clinicians need to know now.

What Is Conversion Therapy? 

Conversion or reparative therapy refers to any practice that attempts to change an individual’s sexual orientation or gender expression or identity. 

Conversion therapy primarily takes the form of talk therapy — counseling sessions that treat same-sex attraction or gender identity as a disorder to be corrected, often by probing for supposed psychological causes or reinforcing gender stereotypes.

A 2023 report from the nonprofit advocacy group the Trevor Project identified more than 1300 conversion therapy practitioners across the US. According to data from the Williams Institute at the UCLA School of Law, nearly 700,000 adults and 350,000 adolescents have received conversion therapy. 

Research has shown that conversion therapy is ineffective and causes significant harm, including depression, anxiety, and increased risk of suicide, particularly among minors.

The practice has been repudiated numerous US medical professional groups, including the American Psychiatric Association (APA), the American Academy of Child and Adolescent Psychiatry, the American Academy of Pediatrics, and the American Medical Association. 

Conversion therapy is banned or restricted in 27 states and the District of Columbia. Eighteen states have no laws regarding conversion therapy and five states — Indiana, Alabama, Georgia, South Carolina, and Florida — have legislation or court rulings that block local ordinances from banning or restricting conversion therapy. 

What Was the Case About? 

The case centered on Kaley Chiles, a licensed Christian counselor in Colorado who challenged the state’s 2019 law prohibiting licensed mental health professionals from engaging in any practice that “attempts or purports to change” a minor’s sexual orientation or gender identity. Violations were treated as unprofessional conduct, subject to fines or license suspension. The law exempted religious counselors.

The law allowed clinicians to affirm a minor’s identity but prohibited them from counseling toward changing it. Chiles argued that the law violated her free speech rights by restricting what she could say in talk therapy sessions, specifically, that she could affirm a minor’s sexual orientation or gender identity but could not counsel toward changing it.

Writing for the majority, Justice Neil Gorsuch held that Colorado’s law “regulates speech based on viewpoint.” However, he noted an exception: Speech that constitutes fraud is not protected by the First Amendment. Ingelhart said Colorado could still win on that basis. 

“It could still be that the state of Colorado will be successful in saying that talk therapy, when it’s conversion therapy, falls under the fraud exception,” she said.

Justice Ketanji Brown Jackson, the lone dissenter in the 8-1 ruling, warned the ruling “opens a dangerous can of worms” for states’ ability to regulate medical care, citing the medical consensus that conversion therapy falls outside the standard of care.

What Does This Mean for Clinical Practice? 

For clinicians in states with conversion therapy bans, the immediate question is practical: What do you say when a parent brings in a minor and requests conversion therapy?

The biggest misconception about the ruling is that it immediately overturns all state bans, said Carl Charles, JD, counsel at Lambda Legal, New York City. 

“This does not automatically overturn every ban,” he told Medscape Medical News. “It’s going to necessitate that someone bring a lawsuit and challenge bans in every single state.”

The ruling also should not be misread as granting permission, he added. 

“This is not a green light to practitioners who want to engage in conversion therapy. They are still subject to bans that are legally in place, and that can be enforced against them,” he said. 

Rebecca Brendel, MD, JD, past president of the APA and director of the Center for Bioethics at Harvard Medical School in Boston, said the answer lies in the physician’s core responsibility. 

“Parents may have distress, concern, and misunderstanding about what it means for a child to be questioning their gender identity or their sexual orientation,” Brendel told Medscape Medical News. “It’s the job of that clinician to engage with the family in understanding, educating, and sharing what evidence-based treatment is to help that child have the best life.”

If a parent threatens legal action against a clinician who declines, Charles said there is little basis for such a claim. 

“The conversion therapy bans don’t create a right of action for people to sue practitioners for not providing this care,” he said. “Clinicians who are abiding by the ethical and professional standards in their state have that defense.”

And critically, the ruling does not mean that practitioners who provide conversion therapy are now legally protected, according to Ingelhart. “Boards can still enforce it, because this is not a final decision on whether or not conversion therapy in the form of talk therapy is protected First Amendment speech.”

Brendel said the professional consensus is clear and legally meaningful. “The standard of care still is that conversion therapy is harmful and is not a standard of care for gender dysphoria or any other psychiatric condition,” she said.

What Happens Next? 

Legal challenges to existing bans in other states are likely, Charles said. “I don’t know if it will be a wave or a ripple.” 

Ingelhart said LGBTQ+ minors are not less protected today than before the ruling, though the decision “is giving some credence to what feels more like a fringe idea.”

For clinicians, Charles offered reassurance: “Clinicians and other people who are seeking out affirming care should feel like they have a strong foundation underneath them [to rely on evidence-based practices].”

Brendel agreed. 

“This legal uncertainty does not change the responsibilities of every physician to deliver the standard of care to their patients,” she said. “Regardless of what court ruling there is, regardless of what the law is, physicians have always and will always, to the best of their ability, act in the interest of the patients before them.”

But she noted that with the legal landscape uncertain, patients harmed by conversion therapy may now bear more of the burden.

Ingelhart, Charles, and Brendel reported no relevant financial relationships.