Late last month, the U.S. Supreme Court declined to review a federal appeals court ruling that found that people with gender dysphoria are entitled to the protections of the Americans with Disabilities Act.

By refusing to review the appeals court’s decision, the high court leaves the ruling by the 4th U.S. Circuit Court of Appeals in place. 

Under the lower court’s ruling, people with gender dysphoria are entitled to reasonable accommodations, similar to those that would be afforded to other groups of people with recognized disabilities.

It also means that transgender people who have been diagnosed with gender dysphoria cannot be discriminated against in employment, transportation, public accommodations, and access to state and local government programs and services based solely on their condition.

The ruling is binding in the states covered by the 4th Circuit: Maryland, Virginia, West Virginia, North Carolina, and South Carolina.

Justice Samuel Alito, joined by Justice Clarence Thomas, penned a dissent arguing that the high court should have taken up the case and considered overturning the 4th Circuit’s ruling — the first in the country to find that the ADA protects transgender people who experience anguish or mental distress due to the incongruence between their assigned sex at birth and their gender identity.

Alito argued that allowing the appeals court’s ruling to stand would raise a “host of important and sensitive questions” on how courts deal with restrictions on transgender athletes, the use of traditional pronouns, and restrictions on access to gender-affirming care. 

“The Fourth Circuit’s decision makes an important provision of a federal law inoperative and, given the broad reach of the ADA and the Rehabilitation Act, will have far-reaching and important effects across much of civil society in that Circuit,” Alito wrote.

“Voters in the affected States and the legislators they elect will lose the authority to decide how best to address the needs of transgender persons in single-sex facilities, dormitory housing, college sports, and the like.”

LGBTQ advocates praised the ruling as a possible tool that could be used to challenge a host of state laws seeking to restrict transgender people’s ability to obtain certain medical treatments for gender dysphoria or access facilities that do not match their assigned sex at birth.

“By declining to hear this case, the Supreme Court implicitly acknowledges what those who have seriously examined the issue have concluded: the ADA protects people who experience gender dysphoria, including transgender and nonbinary people, from being discriminated against on that basis,” Olivia Hunt, the policy director for the National Center for Transgender Equality, told the Associated Press. 

In the underlying case that led to the 4th Circuit’s decision, Kesha Williams, a transgender woman from Virginia, sued Fairfax County Sheriff Stacey Kincaid, as well as a prison nurse and a deputy.

She alleged that the prison where she had been housed had violated both the ADA and the Rehabilitation Act by failing to adequately treat her gender dysphoria, which required allowing her to access hormone medication and be socially affirmed as a female.

Williams was initially housed in a women’s unit at the Fairfax County Adult Detention Center, but was moved to the men’s facility after she informed a nurse that she is transgender and had not undergone gender confirmation surgery.

Following her transfer, Williams was subjected to mistreatment and harassment at the hands of guards and fellow prisoners.

Prison officials also refused to allow her to wear women’s clothing and access gender-affirming toiletries, denied her access to her hormone medication for weeks at a time, denied a request to allow her to shower privately, and forced her to submit to body searches by male prison staff, at least one of whom injured her during such a search.

The Fairfax County Sheriff’s Office had argued that gender dysphoria is not a “disability” under the ADA because it is “an identity disorder not resulting from physical impairments.”

The federal law, which was adopted in 1990, states that gender identity disorders did not qualify as “disabilities” — a distinction that LGBTQ advocates have sought to counter, arguing that the law’s definitions are based on outdated understandings of gender identity and gender dysphoria.

A federal judge initially dismissed Williams’s lawsuit based on the strict interpretation of the ADA’s text, finding that individuals suffering from gender dysphoria were not entitled to protection under the act.

But the 4th Circuit reversed that ruling, noting that there is a distinction between gender dysphoria and gender identity disorder — the latter of which has been removed from the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders.

Meanwhile, the 4th Circuit also recognized that gender dysphoria can cause “clinically significant distress” among transgender people, leading to depression, intense anxiety, and even suicidal ideation.