As a Missouri law banning transgender surgeries and new prescriptions for puberty blockers and cross-sex hormones for minors goes into effect, despite the efforts of LGBTQ activists to block the measure, the debate in the courts over such bans is far from settled, suggesting the issue could reach the Supreme Court.

Legal battles in Missouri and other states over bans on so-called “gender affirming” care for minors are just beginning, with judges in different states making contradictory rulings, raising the chances of a split among federal appellate circuits. Such a split would likely need to be resolved by America’s highest court.

Missouri is among 20 states that have passed outright bans or severe restrictions on transgender medical care for minors, most in the last year. LGBTQ and civil rights groups have sued to block these new laws in at least 13 states with some success.

In June, a federal judge permanently blocked Arkansas from implementing its ban on “gender affirming” care for minors, writing that the ban would violate plaintiffs’ constitutional rights and that “they would suffer immediate and irreparable harm.” Judges have also blocked — in whole or in part — new laws in Florida, Georgia, and Indiana barring the care.

On Friday, though, these LGBTQ rights groups faced a major setback. A Missouri state judge, Steven Ohmer, denied a request to block the Missouri law from going into effect while a legal challenge from the ACLU and other groups makes its way through the courts.

In addition to barring transgender surgeries, puberty blockers, and hormones for minors — except for those already prescribed these drugs — the law also prohibits Medicaid from covering this care for adults. This means that gender-affirming surgeries, such as double mastectomies, phalloplasties, vaginoplasties, and hysterectomies, will no longer be covered by Medicaid. Medical providers can lose their professional licenses for violating the act. 

“The science and medical evidence is conflicting and unclear. Accordingly, the evidence raises more questions than answers,” Judge Ohmer wrote in his ruling. “As a result, it has not clearly been shown with sufficient possibility of success on the merits to justify the grant of a preliminary injunction.”

Missouri’s Republican attorney general, Andrew Bailey, celebrated. “Missouri is the first state in the nation to successfully defend at the trial court level a law barring child mutilation,” Mr. Bailey said in a statement. “This is a huge step in the right direction.”

The ACLU, though, is vowing to continue its fight. “While we are disappointed in and disagree with the court’s ruling, we will not stop fighting to protect the rights of transgender people in Missouri,” a deputy director of communications for the ACLU of Missouri, Tom Bastian, tells the Sun in a statement.  “The case is not over and will go to a full trial on the merits.”

The Missouri ban gained national attention after a whistleblower at a pediatric gender clinic at St. Louis, Jaime Reed, accused the clinic of hastily prescribing hormones and puberty blockers to children with psychiatric problems above and beyond their gender issues. Ms. Reed, whose husband is a transgender man and who previously supported this type of care, testified in favor of Missouri’s new law.

The issue of transgender medical care for minors has become a flashpoint in the culture wars as the number of youth identifying as transgender has doubled in the last five years, and the number of minors receiving puberty blockers and cross-sex hormones has also doubled. Ms. Reed said the clinic she worked at was overwhelmed with new cases, primarily from natal girls, who now make up the vast majority of cases nationwide — a reversal of historical trends.

A Texas judge on Friday ruled in the opposite direction of Missouri, siding with a group of parents suing to block a Texas ban on “gender affirming” care for minors. In issuing a temporary block on the Texas law, Judge Maria Cantu Hexsel wrote that the state’s ban would discriminate against transgender children and deprive them of “necessary, safe, and effective medical treatment.”

The Texas attorney general, Ken Paxton, quickly appealed the ruling to keep the judge’s block from taking effect before the Texas law is set to take effect on September 1. Mr. Paxton’s office wrote in a statement that it “will continue to enforce the laws duly enacted by the Texas Legislature and uphold the values of the people of Texas by doing everything in its power to protect children from damaging ‘gender transition’ interventions.” 

The conflicting rulings mirror the uncertainty around medicalized gender care for minors that is playing out in the medical community as well. Most major American medical organizations support “gender affirming” care for minors, including the American Academy of Pediatrics.

A growing group of medical providers, though, is sounding the alarm on the role “social contagion” — peer pressure and social media — may play in the rise in gender dysphoria diagnoses. They also point to England, Sweden, Finland, and Denmark, which have severely restricted medicalized transgender care for minors after completing systemic reviews of the efficacy of this care.

Proponents of “gender affirming” care say early medicalization can be lifesaving and that these children are at already higher risks for suicide. Critics of “gender affirming” care say that 80 percent of gender dysphoric kids grow out of their dysphoria if left alone and that “watchful waiting” with psychological care is the best approach.

Several prominent detransitioners have also come forward in the last year — a handful now suing their medical providers — which is highlighting the scant evidence on the long-term rates of satisfaction among those who transition as minors.  

Earlier this month, the American Academy of Pediatrics reaffirmed its support for “gender affirming” care at its annual meeting in Illinois, but it also commissioned a systemic review of the evidence for the first time.