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The US supreme court ruled 8-1 this week against a Colorado law banning “conversion therapy” for youth, in a case that could have major consequences for transgender and queer youth across the US, and for healthcare more broadly.

Colorado’s 2019 law prohibits licensed clinicians from seeking to change the gender identity or sexual orientation of youth patients under 18. It is one of 23 states with similar restrictions.

Chiles v Salazar was brought by Kaley Chiles, a licensed counselor who argued Colorado’s ban infringed on her free speech rights to talk with patients about her faith and beliefs on “biological sex”. She was represented by the Alliance Defending Freedom, a Christian legal group behind major anti-abortion and anti-LGBTQ+ cases.

The court’s ruling argued Colorado’s ban censored Chiles’ speech and sent the case back to a lower court where the law will face a more rigorous review. Two liberal justices, Elena Kagan and Sonia Sotomayor, joined the conservative majority. Ketanji Brown Jackson was the sole dissenter, arguing the state has the right to restrict a “dangerous therapy” that has caused “lasting psychological harm”. Leading medical groups, including the American Medical Association and American Psychological Association, have condemned efforts to suppress patients’ LGBTQ+ identities, noting the techniques are not evidence-based and are linked to increased depression and suicide attempts.

The Guardian spoke to three lawyers at leading LGBTQ+ legal advocacy groups and one policy expert about what the ruling means for Colorado and other states, how advocates are responding, and why two liberals sided with Chiles.

What is the immediate impact for LGBTQ+ people in Colorado?

The supreme court ruled Colorado’s “conversion therapy” ban was “presumptively unconstitutional”, since the law restricted Chiles’ speech based on her viewpoint. The justices sent the case back to an appeals court, where it will be subject to “strict scrutiny”. That is a much higher standard, and one that experts say Colorado will very likely fail to meet. But Colorado’s law, for now, remains in effect.

“For Colorado and LGBTQ+ young people or people who may be questioning their sexual orientation or gender identity, this ban will still be in place until the appeals court says something different,” said Carl Charles, counsel for trans and non-binary rights at Lambda Legal, an LGBTQ+ rights group.

How will the ruling affect the 22 other states that have passed restrictions on conversion practices?

The Chiles ruling threatens bans across the country, including in states like California that have restricted these practices for more than a decade. Many of the bills enacted across the US take a relatively similar approach to Colorado’s ban, which means they could run afoul of the supreme court’s ruling, said Elana Redfield, federal policy director at UCLA’s Williams Institute.

Depending on the particulars of the laws and legal challenges they face, some could be struck down. Others may remain on the books, but become unenforceable, in the same way some states continue to have gay marriage bans even after the supreme court legalized marriage equality, Redfield said.

The bans on conversion practices often weren’t being enforced in the first place, she noted. Colorado said last year it had not issued any disciplinary proceedings under its law. And youth who continue to endure conversion practices often are seen by religious counselors or coaches not subject to state bans, which regulate healthcare providers.

“[The ruling] might not change too much on the ground for the practice of conversion therapy, but it certainly has an important and potentially devastating message for people who have experienced harm from conversion therapy,” said Redfield.

If bans are overturned, what does that mean for youth subjected to conversion practices?

While the supreme court found Colorado’s law violated clinicians’ free speech, the justices did not endorse conversion practices, said Josh Rovenger, legal director of Glad Law, an LGBTQ+ legal services group.

“The supreme court didn’t say conversion therapy is safe or legal,” he said. “Conversion therapy can still constitute malpractice and consumer fraud under different state laws, and the supreme court’s resolution of the narrow question about how states can preventatively regulate conversion therapy doesn’t impact that.”

If bans are struck down, the onus falls to individual patients to hold harmful clinicians accountable, Rovenger said. “While survivors can certainly seek redress after they’ve been harmed, the absence of preventative regulation means some of these practices may pop up again and that has real concrete impacts on youth, like increased suicidality, anxiety and depression.”

Redfield pointed to a 2015 New Jersey case in which a jury ruled conversion practitioners had engaged in consumer fraud. She noted research has consistently shown these practices aren’t effective at changing people’s identities. “We have such good evidence that conversion therapy is essentially akin to snake oil in the sense that it’s something people sell you that cannot do what it’s supposed to do.”

Are there other ways states can regulate conversion practices?

Lambda Legal is backing a proposed bill in California that would allow survivors of conversion practices to seek civil remedies through malpractice lawsuits, even if years have passed.

“Giving a path for increased liability for practitioners of this discredited practice is one way to relegate it to the dustbin of history – to let the market shift and not allow for this kind of treatment,” said Charles. But, Charles said, it would be an uphill battle to pass new liability legislation in states across the US given the legal complexities and scrutiny the proposals would face.

Will the ruling have impacts beyond conversion practices?

Jackson’s dissent raised alarms about “potential long-term and disastrous implications of this ruling”. She wrote:

Because the majority plays with fire in this case, I fear that the people of this country will get burned. Before now, licensed medical professionals had to adhere to standards when treating patients: They could neither do nor say whatever they want. Largely due to such state regulation, Americans have been privileged to enjoy a long and successful tradition of high-quality medical care. Today, the court turns its back on that tradition. And, to be completely frank, no one knows what will happen now.”

The ruling, she said, means Colorado cannot legislate to protect children if those protections happen to limit what healthcare providers can say to minors. Taking away a state’s ability to regulate licensed medical professionals’ speech “opens a dangerous can of worms”, “threatens to impair states’ ability to regulate the provision of medical care in any respect” and “risks grave harm to Americans’ health and wellbeing”.

Redfield said there were many ways the ruling could be weaponized: if a doctor didn’t believe insulin worked for diabetes, could they tell a patient not to take it?

“Everybody should take warning from Justice Jackson’s dissent because this opens the door to a broad range of quackery and concerning practices that can now occur in the context of the provision of medical care,” she said.

On the flip side, Shayna Medley, senior staff attorney for Advocates for Trans Equality, which filed an amicus brief in the case, said the ruling could potentially be cited to defend healthcare that is under attack: “The court made a lot of really broad claims about the strength of the first amendment, especially when it comes to medical providers. If the court is going to be consistent, there are opportunities to use that strong language to protect all types of providers. If the first amendment protects people engaging in conversion therapy, it absolutely should protect providers of trans healthcare, of reproductive healthcare.”

Why did two liberal justices side with the conservative majority?

Kagan, supported by Sotomayor, issued a concurring opinion saying Colorado’s law was a “textbook” case of “viewpoint discrimination”, writing: “Because the state has suppressed one side of a debate, while aiding the other, the constitutional issue is straightforward.”

Charles said it was possible the liberal justices were concerned with the widespread assaults on free speech in the US and did not want to open the door to further harmful suppression: “It would not surprise me if the liberal justices were wary of the flipside of this coin … and were concerned about other states enacting viewpoint restrictions on professionals in other ways that could come out equally as harmfully.”

Kagan’s opinion also suggested that Colorado’s ban might not clash with the first amendment if it was a “viewpoint-neutral law”. But Charles questioned how legislators could write a law restricting harmful conversion practices that would be “viewpoint-neutral” and said Kagan’s opinion did not present a pathway.

Charles, who was part of an amicus brief of survivors of conversion practices, noted that Jackson was the only justice to meaningfully engage with the severe harms youth face: “Justice Jackson acknowledged the impact of this practice on actual people and the way so many of us couldn’t escape the treatment because we were minors and did not come from accepting families.”