CHILES v. SALAZAR

SUPREME COURT OF THE UNITED STATES

_________________

No. 24–539

_________________

KALEY CHILES, PETITIONER v. PATTY SALAZAR, in her official capacity as EXECUTIVE DIRECTOR  OF THE COLORADO DEPARTMENT OF  REGULATORY AGENCIES, et al.

on writ of certiorari to the united states court of appeals for the tenth circuit

---

---

 Justice Jackson, dissenting.

 “[T]here is no right to practice medicine which is not subordinate to the police power of the States.” Lambert v. Yellowley, 272 U. S. 581, 596 (1926). This was true 100 years ago, and it should be true today.

 Many States have now chosen to exercise their police powers to ban “conversion therapy” based on the medical profession’s broad consensus that this medical treatment (which seeks to change a gay or transgender person’s sexual orientation or gender identity) is ineffective and harmful. This case involves the Colorado Legislature’s policy decision to prohibit licensed medical professionals from offering or providing conversion therapy to minors in that State.

 Petitioner Kaley Chiles is a licensed counselor who works in the State of Colorado. She does not dispute that conversion therapy can be harmful to minors in certain circumstances. Nor does she contest that Colorado has a significant interest in protecting minors from harm. Chiles complains nevertheless that, because the particular form of conversion therapy she wants to offer clients utilizes only speech, the First Amendment prevents Colorado from prohibiting that treatment. But “[t]he power of government to regulate the professions is not lost whenever the practice of a profession entails speech.” Lowe v. SEC, 472 U. S. 181, 228 (1985) (White, J., concurring in result). And “[m]edical professionals do not, generally speaking, have a right to use the Constitution as a weapon allowing them rigorously to control the content of . . . reasonable conditions” that a State imposes on licensed healthcare providers for the protection of its residents. National Institute of Family and Life Advocates v. Becerra, 585 U. S. 755, 785 (2018) (Breyer, J., dissenting) (NIFLA).

 So, I respectfully dissent. Stated simply, the majority has failed to appreciate the crucial context in which Chiles’s constitutional claims have arisen. Chiles is not speaking in the ether; she is providing therapy to minors as a licensed healthcare professional. The Tenth Circuit was correct to observe that “[t]here is a long-established history of states regulating the healthcare professions.” 116 F. 4th 1178, 1206 (2024). And, until today, the First Amendment has not blocked their way. For good reason: Under our precedents, bedrock First Amendment principles have far less salience when the speakers are medical professionals and their treatment-related speech is being restricted incidentally to the State’s regulation of the provision of medical care.

 No one directly disputes that Colorado has the power to regulate the medical treatments that state-licensed professionals provide to patients. Nor is it asserted that, when doing so, a State always runs afoul of the Constitution. So, in my view, it cannot also be the case that Colorado’s decision to restrict a dangerous therapy modality that, incidentally, involves provider speech is presumptively unconstitutional. In concluding otherwise, the Court’s opinion misreads our precedents, is unprincipled and unworkable, and will eventually prove untenable for those who rely upon the long-recognized responsibility of States to regulate the medical profession for the protection of public health.

I

 To properly evaluate the First Amendment claim at issue in this case, one must first understand the impetus for Colorado’s regulation, what that law requires, and the nature of the speech it implicates.

A

 Conversion therapy is designed to “convert” a person’s sexual orientation or gender identity, so that the person will become heterosexual or cisgender. Generally speaking, conversion therapy began as an attempt to “cure” gay and transgender people of their “nonconforming” orientations or identities. Brief for American Psychological Association et al. as Amici Curiae 13.

 Conversion-therapy efforts have historically included aversive therapeutic modalities. Those ranged from inducing nausea, vomiting, or paralysis in patients or subjecting them to severe electric shocks to telling patients to snap an elastic band on their wrists in response to nonconforming thoughts. Aversive therapies have now fallen out of fashion; nonaversive treatments—primarily, talk therapy—are currently the predominant form of conversion therapy. All such therapies seek to encourage patients to change their behavior in an attempt to “change” their identity.

 Over the past few decades, however, the premise of conversion therapy (in whatever form) has been widely discredited within the medical and scientific community. Conversion therapy is, at bottom, “based on a view of gender diversity that runs counter to scientific consensus.” Substance Abuse and Mental Health Services Administration (SAMHSA) Report, 2 App. 570. That is, contrary to the core beliefs that undergird conversion therapy, a robust professional consensus now acknowledges that sexual orientations and gender identities range widely. And it no longer regards nonheterosexual orientations or noncisgender identities as “nonconforming.”

 Because people’s identities are simply “a part of the normal spectrum of human diversity,” id., at 535, the medical community has determined that efforts to change a patient’s sexual orientation or gender identity will necessarily be ineffective. The American Psychological Association (APA), for example, has found “no empirical evidence that providing any type of therapy in childhood can alter adult same-sex sexual orientation.” APA Report, 1 App. 360. And “[n]o research has been published in the peer-reviewed literature that demonstrates the efficacy of conversion therapy efforts with gender minority youth, nor any benefits of such interventions to children and their families.” SAMHSA Report, 2 App. 569.

 Not only is conversion therapy ineffective, former participants of conversion therapy report that it causes lasting psychological harm. Gay and transgender children who underwent nonaversive conversion therapy say they were taught to feel shame and self-hatred. See Brief for Conversion Therapy Survivor Network et al. as Amici Curiae 11–14. And survivors of conversion therapy continue to suffer from PTSD, anxiety, and suicidal ideation. Id., at 19–22. As one survivor put it, conversion therapy “ ‘came close to killing me.’ ” Id., at 17.¹

 The scientific literature confirms what anecdotal experiences suggest: Conversion therapy has harmed patients, particularly minors. The APA found that “the reported negative social and emotional consequences [of conversion therapy] include self-reports of anger, anxiety, confusion, depression, grief, guilt, hopelessness, deteriorated relationships with family, loss of social support, loss of faith, poor self-image, social isolation, intimacy difficulties, intrusive imagery, suicidal ideation, self-hatred, and sexual dysfunction.” APA Report, 1 App. 253–254. Even for those study participants who reported positive effects initially, many described experiencing the negative effects later. Id., at 254. Moreover, studies show that children often feel the effects of the shame and stigma from conversion therapy even more vividly than adults due to their “increased emotional vulnerability and less developed capacity to cope effectively with the harm of discrimination.” Glassgold Decl., 1 App. 53–54, ¶ 50.

 Ultimately, scientific evidence supports the conclusion that the anticipated harms from conversion therapy are twofold. First, conversion therapy stigmatizes the patient, telling them that their gender identity or sexual orientation is something to be fixed, rather than accepted. This rejection can lead to shame and guilt, which in turn can cause long-term emotional distress. Second, conversion therapy sets patients up to fail by giving them an unattainable goal. Some patients have described that experience of failure “as a significant cause of emotional and spiritual distress and negative self-image.” Id., at 63, ¶ 66.

B

 In 2019, Colorado joined 25 other States in banning the practice of conversion therapy for minors. Colorado’s law—titled the Minor Conversion Therapy Law (MCTL)—prohibits licensed healthcare professionals from practicing conversion therapy with children. It defines conversion therapy as “any practice or treatment” that “attempts or purports to change an individual’s sexual orientation or gender identity, including efforts to change behaviors or gender expressions or to eliminate or reduce sexual or romantic attraction or feelings toward individuals of the same sex.” Colo. Rev. Stat. §12–245–202(3.5)(a) (2025).²

 Not all therapeutic discussions of sexuality and gender identity are prohibited by the MCTL. The law allows

 “practices or treatments that provide:

 “(I) Acceptance, support, and understanding for the facilitation of an individual’s coping, social support, and identity exploration and development, including sexual-orientation-neutral interventions to prevent or address unlawful conduct or unsafe sexual practices, as long as the counseling does not seek to change sexual orientation or gender identity; or

 “(II) Assistance to a person undergoing gender transition.” §12–245–202(3.5)(b).

 The Colorado Legislature made these allowances after crediting witness testimony and the professional consensus about conversion therapy—namely, that it is harmful, and that the preferred treatment for minors relating to their sexual orientation and gender identity is affirming care (i.e., medical care that helps minors focus on acceptance, support, coping, and identity exploration and development). Prohibit Conversion Therapy for a Minor: Hearing on H. B. 19–1129 before the House Committee on Public Health Care & Hum. Servs., 2019 Leg., 72d Gen. Sess. (Colo., Feb. 13, 2019).

C

 Chiles insists that, although she is a counselor licensed by Colorado, she has a constitutional right to flout Colorado’s statute and the standard of care it incorporates if a client asks her to do so. Never mind that medical professionals—including counselors like Chiles—are generally bound to follow medical standards and state licensing requirements when they provide medical care to patients. Chiles wants to offer patients conversion therapy despite the MCTL and the medical consensus it reflects. So she has invoked the First Amendment, arguing that, because talk therapy is speech, no State can impose treatment standards like the MCTL on licensed talk therapists without first satisfying heightened scrutiny.

 As applied to Chiles, the MCTL treats the talk-therapy form of conversion therapy as a prohibited medical treatment. But Chiles is free to express her opinion about the efficacy of conversion therapy or her disagreement with Colorado’s conclusion that such therapy is harmful to minors. Colorado’s law does not target or prohibit the expression of such views by anyone in any form—including by licensed healthcare providers in discussions with patients and their families. All that Colorado’s law proscribes is the provision of such therapy to minors. This means that, while Chiles can freely promote conversion therapy and vociferously decry the State’s prohibition, she cannot practice that therapy without being subject to professional discipline under Colorado law.

II

 I begin my analysis with a simple observation: Our First Amendment jurisprudence does not treat speech as existing in a vacuum. Instead, how the First Amendment applies to a State’s power to regulate speech depends upon the context in which the regulation of speech occurs. See, e.g., Vidal v. Elster, 602 U. S. 286 (2024) (trademark context); Tinker v. Des Moines Independent Community School Dist., 393 U. S. 503 (1969) (school context). We have not mechanically held that the First Amendment protects all communicative content; rather, we have evaluated First Amendment claims in a nuanced way, sensitive to both core principles and the specific circumstances under which the claim arises. See, e.g., Virginia Bd. of Pharmacy v. Virginia Citizens Consumer Council, Inc., 425 U. S. 748, 758, 762–770 (1976) (considering First Amendment principles in the commercial speech context).

 In my view, then, it matters for First Amendment purposes that the MCTL restricts treatment-related speech uttered by medical professionals only as part of a larger regulatory scheme aimed at ensuring that providers tender high-quality medical care to patients.

 In Part II–A, I explain that this way of conceptualizing the question before us is not novel—we have long understood that States have the power to regulate medical professionals. And our precedents demonstrate that, when a healthcare provider’s speech is incidentally restricted as part of a state-law scheme regulating the provision of medical treatments, the heightened scrutiny we reflexively apply in other situations is not warranted. In Part II–B, I show that First Amendment principles are not offended when lesser scrutiny is applied to a state law regulating medical treatments in a manner that incidentally restricts a provider’s professional medical speech.

A

1

 A case that we decided in 2018—NIFLA—shows us the way to determine the appropriate level of constitutional scrutiny here. 585 U. S. 755. In that case, we began by explaining that “[s]peech is not unprotected merely because it is uttered by ‘professionals.’ ” Id., at 767; see also ante, at 10–11, 14. But, critically, we also acknowledged that the Court has afforded less protection for professional speech in two circumstances—one of which occurs when a State “regulate[s] professional conduct, even though that conduct incidentally involves speech.” NIFLA, 585 U. S., at 768; see ante, at 11. This acknowledgement was grounded in an already well-established principle: “[T]he First Amendment does not prevent restrictions directed at . . . conduct from imposing incidental burdens on speech.” Sorrell v. IMS Health Inc., 564 U. S. 552, 567 (2011).

 To further explain the contours of this presumptively permissible speech restriction, NIFLA cited Planned Parenthood of Southeastern Pa. v. Casey, 505 U. S. 833 (1992). In Casey, the Court assessed “an asserted First Amendment right of a physician not to provide information about the risks of abortion, and childbirth, in a manner mandated by the State.” Id., at 884 (joint opinion of O’Connor, Kennedy, and Souter, JJ.). More specifically, Casey involved a challenge to a Pennsylvania law requiring that “a doctor give a woman certain information as part of obtaining her consent to an abortion.” Ibid.³ We held that Pennsylvania’s informed-consent mandate did not violate the First Amendment. “To be sure, the physician’s First Amendment rights not to speak [were] implicated” by Pennsylvania’s law. Ibid. But we emphasized that those rights were implicated “only as part of the practice of medicine, subject to reasonable licensing and regulation by the State.” Ibid. (emphasis added). Thus, there was “no constitutional infirmity in the requirement that the physician provide the information mandated by the State.” Ibid.

 In NIFLA, we reaffirmed the principle from Casey that the First Amendment inquiry requires consideration of whether the regulated speech was made during the provision of medical care. NIFLA involved a challenge to a California law that required certain crisis pregnancy centers to post notices in their waiting rooms informing low-income patients that California paid for qualifying abortions. 585 U. S., at 762–763. We asked whether, on the one hand, this law was regulating the clinics’ speech qua speech, or whether, on the other, the notice requirement was actually regulating the clinics’ professional conduct and only incidentally restricting speech. If the latter, the NIFLA Court explained, California’s notice requirement would fit into the category of cases that Casey illustrated; namely, those in which “this Court has upheld regulations of professional conduct that incidentally burden speech.” 585 U. S., at 769.

 Relying in part on Casey’s analytical framework, the NIFLA Court held that California’s law regulated “speech as speech.” 585 U. S., at 770. We explained this conclusion by contrasting the Pennsylvania regulation at issue in Casey: While the notice requirement in Casey restricted doctors’ speech, it did so “only ‘as part of the practice of medicine.’ ” 585 U. S., at 770. The notice requirement at issue in NIFLA, by contrast, was “not an informed-consent requirement or any other regulation of professional conduct.” Ibid. “In fact,” California’s notice was “not tied to a procedure at all. It applie[d] to all interactions between a covered facility and its clients, regardless of whether a medical procedure [was] ever sought, offered, or performed.” Ibid. (emphasis added). So, we reasoned, unlike Pennsylvania’s informed-consent requirement in Casey, California’s notice mandate warranted heightened scrutiny because it “regulate[d] speech as speech.” 585 U. S., at 770.

 The takeaway from NIFLA is that Casey applied a lower level of scrutiny because the law in Casey restricted speech uttered in the course of—and as a part of—providing professional medical care. By contrast, the notice requirement in NIFLA was not “tied to a procedure at all” and was therefore meaningfully different: That law restricted “speech as speech.” 585 U. S., at 770. Thus, the key distinction, as the NIFLA Court saw it, was whether the challenged law was a regulation of speech as such or a regulation of “professional conduct that incidentally burden[ed] speech.” Id., at 769.

2

 Given all this, one might think today’s majority would make more of an effort to explain why the MCTL does not likewise qualify as a regulation of “professional conduct that incidentally burden[s] speech.” Ibid.; see ante, at 14–17. Such an inquiry would entail evaluating whether the MCTL’s restriction on Chiles’s therapy only “incidentally” restricts Chiles’s speech by virtue of the fact that the medical care she provides is delivered orally. It would also require acknowledging that the MCTL’s restriction on Chiles is plainly “tied to [the provision of] a [medical] procedure,” NIFLA, 585 U. S., at 770—one that, but for Colorado’s law, a licensed counselor like Chiles might offer to minors.

 In my view, it is obvious that the MCTL is regulating professional conduct insofar as it prohibits providing a particular therapy; the aim of the statute is not suppressing speech. Indeed, Chiles’s claim that her (otherwise protected) speech is being swept up by Colorado’s (otherwise valid) treatment prohibition proves that very point. This set of circumstances seems to fit NIFLA’s idea of permissible state “regulation of professional conduct” that “incidentally burdens speech” to a “T.”

 Yet, the majority strangely suggests otherwise with the opinion it hands down today. Ante, at 14–17. The majority does this primarily by eschewing serious engagement with the interaction between NIFLA and Casey. Its workaround seems to be: The First Amendment applies full bore here because Chiles’s speech is being impacted; after all, she is a talk therapy provider. Ante, at 12–17. But when NIFLA’s teachings are properly understood, this comeback is no answer. Yes, Chiles happens to be talking when she’s providing therapy to patients, but the MCTL regulates the provision of medical treatments by licensed medical professionals, which States are fully empowered to do. That Chiles’s kind of medical care involves talk therapy is, in NIFLA’s words, merely “incidenta[l].” 585 U. S., at 769.

 I am the first to admit that, as applied to talk therapists like Chiles, the MCTL restricts speech—I do not argue that this law really just limits Chiles’s professional conduct. See ante, at 12–13, 16 (characterizing Colorado’s argument). Similarly, I do not maintain that, because this law primarily regulates talk-therapists’ professional conduct, it should not be conceived of as a speech restriction. See ante, at 16. I agree with the majority that, in cases like Cohen v. California, 403 U. S. 15 (1971), we firmly rejected a State’s attempt to suppress free speech by calling the restricted expression “conduct.” Ante, at 16. But, here, the observation that the MCTL indeed restricts Chiles’s “speech” (not reformulated as conduct) just raises the question that this case presents: Whether the MCTL is restricting Chiles’s speech “incidentally” to its regulation of medical professionals’ treatment-related conduct, such that the law warrants less scrutiny under the First Amendment than a law that restricts her speech “as speech.” NIFLA, 585 U. S., at 769–770.

 The majority’s failure to acknowledge that this is the actual issue here—not just whether Chiles’s “speech” or “conduct” is being restricted, but what the State is doing—ignores what has always been true under our precedents. The real lesson of NIFLA’s discussion of Casey is this: When a healthcare professional’s speech is not being targeted “as speech” (because it conveys an idea) but is instead “incidentally” restricted due to a State’s otherwise legitimate regulation of the medical treatments being offered to patients, heightened scrutiny is not warranted. 585 U. S., at 769–770; Casey, 505 U. S., at 884 (joint opinion of O’Connor, Kennedy, and Souter, JJ.).

3

 NIFLA’s focus on a State’s regulation of medical treatments also undermines the position the United States has taken on today’s First Amendment question. The United States, joining this case as amicus curiae, insists, in essence, that when the NIFLA Court acknowledged that States can regulate professional conduct while “incidentally” restricting speech, it was blessing only two circumstances: (1) where the speech that is being restricted is inextricably tied to an act of the speaker (so, speech-only therapists are never included), or (2) where speech is being regulated in a manner entirely unrelated to its content. Brief for United States as Amicus Curiae 17–21; see ante, at 11, 15–16. But, under NIFLA’s reasoning, that cannot be so—at least not logically.

 With respect to the first category, the United States mistakenly swaps “integral” (i.e., whether the restricted speech is bound up with the regulated conduct) for “incidental”—but these are two completely different concepts.⁴ Given NIFLA’s focus on the “incidental” nature of the challenged speech restriction, the State’s objective is the actual fulcrum: We ask whether, on the one hand, the State’s law is restricting the provider’s speech “incidentally” (meaning in the course of the State’s pursuit of its primary objective of regulating the provision of medical care), or whether, on the other, the State’s law is restricting her speech “as speech” (primarily to suppress its message or expressive content). 585 U. S., at 769–770. The appropriate scrutiny level logically follows: Incidentally restricting speech needs less scrutiny because we view the State as generally regulating the provision of medical care, while restricting “speech as speech” receives heightened scrutiny because the State is aiming at professional speech qua speech.

 The second “speech incident to conduct” category the United States advances—whether the restriction on speech is unrelated to its content—is also fatally flawed. It ignores what NIFLA plainly recognizes: that States can regulate the medical treatments healthcare professionals provide to patients without running afoul of the First Amendment, even if the regulation applies to and restricts speech based on its content. 585 U. S., at 769–770. In other words, what mattered to NIFLA’s analysis was not that the regulation was content-based, but instead that the speech was being restricted incidentally.

 So it is here. Talk therapy is a medical treatment. 116 F. 4th, at 1206, 1208–1210. So, why wouldn’t such speech-based medical treatments be subject to reasonable state regulation like any other kind of medical care? The United States and the majority just insist that a law that undertakes to regulate speech-based medical treatments is presumptively unconstitutional because the treatment is being administered solely through speech. But that reasoning is maddeningly circular, and it is based on happenstance, not logic. Even more important, it is not the rationale upon which NIFLA’s analysis relies. To the contrary, with its description of Casey, NIFLA recognizes precisely the opposite—a State can regulate professionals’ treatment-related conduct even if doing so impacts treatment-related speech.

 Again, what distinguished NIFLA from Casey was the fact that Pennsylvania’s speech-related mandate was aimed at regulating the provision of medical treatments to patients; the fact that the particular medical treatment at issue in Casey involved a physical (instead of a verbal) act was of no moment. NIFLA, 585 U. S., at 769–770. The reading of NIFLA the United States favors—which the majority appears to endorse in part, see ante, at 16–17—is irrational because, for purposes the State’s regulation of harmful professional conduct, treatments administered through words versus treatments administered through acts are not meaningfully different.⁵

 By contrast, NIFLA’s actual line marks a real, constitutionally relevant distinction: Restrictions of speech that occur when a State undertakes to regulate the treatments that professionals provide to patients are merely “incidental”; they are materially different from speech restrictions that are not “tied to a [medical] procedure at all.” 585 U. S., at 769–770; cf. Black’s Law Dictionary 686 (5th ed. 1979) (defining “incidental” as “[d]epending upon or appertaining to something else as primary,” such as “something incidental to the main purpose”). The latter warrants strict scrutiny since the State is regulating “speech as speech,” while in the former case—where the State is merely restricting speech due to its regulation of medical treatments—heightened scrutiny is not needed. 585 U. S., at 770.

 The “speech incident to conduct” doctrine thus ably balances the interests at stake by accommodating a State’s traditional police power to regulate the practice of medicine for the protection of its residents while also ensuring that speech is not being targeted. As we explained in NIFLA, that doctrine recognizes that the treatments provided by licensed medical professionals can be prohibited even if, by doing so, the State incidentally restricts those providers’ speech. Id., at 769–770. This is constitutionally permissible precisely because the restricted speech is not being regulated “as speech”—i.e., based on or due to its message or expressive content. Rather, the speech restriction is a mere byproduct of the State’s healthcare regulation.

 So, at the end of the day, I think what we have here is what Casey involved and NIFLA did not: a State restricting a medical provider’s speech only as part of its regulation of the provision of medical treatments to individual patients. See NIFLA, 585 U. S., at 769–770; Casey, 505 U. S., at 884 (joint opinion of O’Connor, Kennedy, and Souter, JJ.). And it is precisely because the MCTL is restricting Chiles’s speech “only as part of [her] practice of medicine” that the First Amendment is not particularly bothered despite the impact on her speech. Casey, 505 U. S., at 884 (same). Accordingly, talk therapists like Chiles—just like any other healthcare provider seeking to treat patients—can presumptively be “subject[ed] to reasonable licensing and regulation by the State.” Ibid.

B

 The conclusion that a State can regulate the provision of medical care even if, in so doing, it incidentally restricts the speech of some providers, fully comports with the First Amendment’s animating principles. These principles include the well-settled notion that context matters when evaluating First Amendment challenges to state regulation. See Virginia Bd. of Pharmacy, 425 U. S., at 762–768 (analyzing the First Amendment protections due speech in the commercial context); cf. Central Hudson Gas & Elec. Corp. v. Public Serv. Comm’n of N. Y., 447 U. S. 557, 564, n. 6 (1980) (explaining how the context and characteristics of commercial speech justify less scrutiny).

 The context that frames today’s debate is the kind of speech that is at issue here—what I am calling (as shorthand) “professional medical speech.” This is the only type of speech the MCTL restricts.

1

 Properly defined, “professional medical speech” is a narrow category. It is not all speech “uttered by ‘professionals.’ ” NIFLA, 585 U. S., at 767. Rather, it is speech by healthcare professionals made as part of their provision of medical care to patients. To be even more specific, professional medical speech occurs when a medical professional speaks to a client (1) in the context of the professional-patient relationship; (2) on matters within the provider’s professional expertise as defined by the medical community; (3) for the purpose of providing medical care. See C. Haupt, Professional Speech, 125 Yale L. J. 1238, 1247–1248 (2016); R. Post, Informed Consent to Abortion: A First Amendment Analysis of Compelled Physician Speech, 2007 U. Ill. L. Rev. 939, 947; D. Halberstam, Commercial Speech, Professional Speech, and the Constitutional Status of Social Institutions, 147 U. Pa. L. Rev. 771, 834 (1999).

 First, professional medical speech is speech uttered within the bounds of the professional-patient relationship. See, e.g., Haupt, 125 Yale L. J., at 1254–1255. That relationship imposes certain duties and restrictions on the medical professional. For example, medical providers are bound by the twin duties of beneficence (the obligation to act for the benefit of the patient) and nonmaleficence (the obligation not to harm the patient). B. Varkey, Principles of Clinical Ethics and Their Application to Practice, 2020 Med. Principles and Prac. 17, 18.⁶

 Second, professional medical speech is speech within the healthcare provider’s area of expertise as a member of the medical community. Haupt, 125 Yale L. J., at 1248–1251. Within the professional-patient relationship, the professional has knowledge that the patient does not have, including knowledge of which medical treatments are appropriate and how to administer them. The patient comes to the provider to access that expertise, which is informed by—and constrained by—what the medical community knows. See id., at 1243.

 Finally, and most importantly, professional medical speech is made for the purpose of providing the patient with medical care. See id., at 1255. This speech is a tool employed to treat patients. In this sense, professional medical speech facilitates the professional’s goal of providing the patient with the treatment, procedure, or healthcare that is within her expertise and that forms the basis of the professional-patient relationship.

2

 Keeping in mind these characteristics of professional medical speech, consider the First Amendment principles that serve as guideposts for determining the level of scrutiny that a government restriction of such speech deserves.

 First, and most fundamentally, is preservation of the marketplace of ideas. See Abrams v. United States, 250 U. S. 616, 630 (1919) (Holmes, J., dissenting); Meyer v. Grant, 486 U. S. 414, 421 (1988). Indeed, the “whole project of the First Amendment” stemmed from the Founders’ desire to protect the “critically important” goal of having “a well-functioning sphere of expression, in which citizens have access to information from many sources.” Moody v. NetChoice, LLC, 603 U. S. 707, 732 (2024). Within the marketplace of ideas, speech that is expressive of the speaker’s thoughts and views is, generally speaking, highly valued. See Leathers v. Medlock, 499 U. S. 439, 447 (1991); Ashcroft v. American Civil Liberties Union, 535 U. S. 564, 573–574 (2002).

 But professional medical speech does not intersect with the marketplace of ideas: “[I]n the context of medical practice we insist upon competence, not debate.” Post, 2007 U. Ill. L. Rev., at 950. The degree to which medical providers speaking within the boundaries of providing patient care can express themselves is limited because their interactions with patients are constrained by their well-established duties to those patients and the requirement that they meet the standard of care. Moreover, given these limits, professional medical speech does not necessarily involve the expression of ideas or messages, so it does not provide significant value to the general marketplace. See Dun & Bradstreet, Inc. v. Greenmoss Builders, Inc., 472 U. S. 749, 758–759 (1985) (plurality opinion).

 That’s not to say that there isn’t a robust marketplace of ideas within the medical community. Medical professionals contribute to that particular marketplace by writing papers, giving speeches, and pushing the bounds of the community’s knowledge through experimentation. And, indeed, the standard of care for a medical treatment can be greatly influenced and changed by virtue of such speech. It is there that truth competes for “accept[ance] in the . . . market.” Abrams, 250 U. S., at 630 (Holmes, J., dissenting). But that marketplace exists outside the confines of the professional-patient relationship. See Haupt, 125 Yale L. J., at 1243–1244 (discussing the epistemic marketplace among medical professionals).

 Within the confines of the professional-patient relationship, treatment-related “truths” are a given—they are set by licensing and malpractice standards, and it is not uncommon that such regulation incidentally restricts provider speech. Moreover, regulation of the practice of medicine is pervasively and unavoidably viewpoint based. The majority and the concurrence both resist this: They relentlessly deride Colorado for engaging in “viewpoint discrimination” by banning conversion therapy but permitting affirming care. Ante, at 13–14 (majority opinion); ante, at 1–2 (Kagan, J., concurring). But context makes that point ring hollow.

 When a State establishes a standard of care, or punishes a doctor for providing care outside of that standard, it necessarily limits what medical professionals can say and do on the basis of viewpoint. A State can permissibly “prohibi[t] the administration of specific drugs for particular medical uses” but not for others. United States v. Skrmetti, 605 U. S. 495, 516 (2025).⁷ So, too, may it prohibit a doctor from encouraging a patient to commit suicide, see Tr. of Oral Arg. 43–45, or a dietician from telling an anorexic patient to eat less, see id., at 22–23. Likewise, no one would bat an eye if a State required its doctors to discourage, but not encourage, smoking tobacco.

 Even though these kinds of regulations are inherently viewpoint based, in the context of medical care, a State can certainly require the medical professionals it licenses to stand on one side of an issue. See Collins v. Texas, 223 U. S. 288, 297–298 (1912) (recognizing the “right of the State to adopt a policy even upon medical matters concerning which there is difference of opinion and dispute”). Though these proscriptions certainly promote a viewpoint, in this context, that alone does not suffice to establish a presumptive First Amendment violation. Instead, under the “speech incident to conduct” doctrine, the challenged laws must also operate as speech-suppression tools, designed to vanquish free expression.

 But, here, Colorado’s clear aim is enforcement of a standard of care that is indisputably applicable to the State’s licensed healthcare professionals. Taking a position as to how those providers should handle a medical issue is the very essence of standard-setting—once again, this kind of viewpoint-based regulation ensures “competence, not debate.” Post, 2007 U. Ill. L. Rev., at 950. My colleagues’ contrary conclusions are puzzling, for a standards-based healthcare scheme cannot function unless its regulators are permitted to choose sides.⁸

 A second and corollary First Amendment principle is the listener’s interest in receiving information. See Murthy v. Missouri, 603 U. S. 43, 75 (2024); accord, Kleindienst v. Mandel, 408 U. S. 753, 762 (1972). In the professional medical context, however, informational asymmetry shapes the listener’s interest. To be sure, “[r]espect for patients’ autonomy is a cornerstone of medical ethics.” American Medical Association Code of Medical Ethics, Opinion 11.2.4: Transparency in Health Care (2026). But that interest is not served by receiving all existing opinions—only information about treatments that are within the standard of care advances patients’ interests. Ibid. (“[P]hysicians have an obligation to inform patients about all appropriate treatment options” (emphasis added)). Patients are not in a position to wade through medical discourse and independently evaluate the best treatment for their circumstances. Their interests as listeners are thus limited by the nature and purpose of the professional-patient relationship.

 Third, and finally, the First Amendment protects a speaker’s autonomy. “ ‘[T]he fundamental rule of protection under the First Amendment [is] that a speaker has the autonomy to choose the content of his own message.’ ” Rumsfeld v. Forum for Academic and Institutional Rights, Inc., 547 U. S. 47, 63–64 (2006) (quoting Hurley v. Irish-American Gay, Lesbian and Bisexual Group of Boston, Inc., 515 U. S. 557, 573 (1995)). But, here again, with respect to professional medical speech, healthcare providers do not have autonomy; when it comes to providing treatments for their patients, they are bound by the standard of care and are not generally free to “choose the content” of their message. See Haupt, 125 Yale L. J., at 1272; Halberstam, 147 U. Pa. L. Rev., at 867. Put differently, although medical professionals do have an autonomy interest in communicating their ideas to the patients they are treating, that interest only extends to treatment-related advice and information that is consistent with the standard of care.

 In my view, the majority is mistaken to equate treatment-related speech rendered in the context of providing medical care with any spoken words uttered by any other speaker. See, e.g., ante, at 11 (“While the First Amendment protects many and varied forms of expression, the spoken word is perhaps the quintessential form of protected speech. And that is exactly the kind of expression in which Ms. Chiles seeks to engage”). The majority is also wrong to insist that it is antithetical to the First Amendment for a State to incidentally restrict a healthcare provider’s treatment-related speech based on a “prevailing ‘standard of care’ ” because “[m]edical consensus . . . is not static; it evolves and always has.” Ante, at 22. The mutability of medical standards tells us little about the First Amendment’s scope in a country where medical standards are enforceable by law and govern the treatment-related conduct of professional healthcare providers.

 Like it or not, treatment standards exist in America. And those standards necessarily reflect the expert medical community’s current beliefs about the safety and efficacy of various medical treatments, whatever those beliefs might be. Medical standards are driven by science (objective facts and data), but, naturally, they are not viewpoint neutral. Consequently, the people win—not lose—when a State incorporates medical profession’s viewpoint into laws that require licensed treatment providers to conform to prevailing standards of care. Contra, ante, at 22 (suggesting otherwise). For this reason, the Court has long recognized a State’s power to regulate to protect its residents even in the face of uncertainty. Cf. Gonzales v. Carhart, 550 U. S. 124, 163 (2007) (collecting cases and noting the “wide discretion” afforded state legislatures to “pass legislation in areas where there is medical and scientific uncertainty”).⁹

 Put differently, States impose treatment standards incorporating the current consensus of medical experts to protect state residents from harm. And they do this to ensure that professionals provide patients with high-quality care. A State that, alternatively, pursues an agenda of purposefully silencing critics, muzzling opponents, or targeting views it considers threatening would, of course, violate the First Amendment. But it behooves us all (and especially courts) to see and know the difference.

 Ultimately, then, no traditional First Amendment principle justifies preventing a State from regulating medical care simply and solely because its law happens to restrict treatment-related speech. And in this case, there is zero evidence that Colorado has engaged in the corrosive and illicit suppression of ideas that the First Amendment valiantly repels. The record here does not show that Chiles is being “target[ed]” or “muzzle[d]” or “silenced” or “censor[ed],” as the majority suggests. Ante, at 14, 15, 22, 23. Instead, as a healthcare provider licensed by the State of Colorado, she is simply being held to the same standard of care that all other licensed medical professionals in that State must follow.¹⁰ The MCTL’s conversion-therapy ban only incidentally restricts professional medical speech as a result of Colorado’s regulation of a harmful medical treatment; nothing compels the conclusion that a state regulation that operates to restrict this kind of communication in this way is targeting speech qua speech.

III

 The centuries-long tradition of States using their police powers to establish and enforce the standards of care that bind medical professionals—including those who use speech to administer treatments—is another indication that heightened scrutiny does not and need not apply here. The majority’s opinion largely omits this broader historical record. But, when consulted, that history demonstrates unequivocally that the MCTL is neither unusual nor inherently suspect.

 States have always had “broad power to establish standards for licensing practitioners and regulating the practice of professions.” Goldfarb v. Virginia State Bar, 421 U. S. 773, 792 (1975). With respect to the medical profession in particular, States have used that power to control how medicine is practiced “from time immemorial.” Dent v. West Virginia, 129 U. S. 114, 122 (1889).

 States have historically regulated the medical profession in two complementary ways: licensing schemes and medical-malpractice liability. Both necessarily encompass restrictions on professional medical speech through the regulation of the provision of medical care.

 Medical licensing began as early as 1639, before this country was founded. R. Horowitz, In the Public Interest: Medical Licensing and the Disciplinary Process 39 (2013). Many States deregulated in the mid-1800s by abolishing their licensing schemes. Id., at 40. But regulation through licensing was not abandoned for long: By the turn of the 20th century, 12 States had adopted licensing laws. D. Johnson & H. Chaudhry, Medical Licensing and Discipline in America: A History of the Federation of State Medical Boards 23 (2012). We held that such laws were a permissible exercise of a State’s traditional police powers, declaring that “[t]he power of the state to provide for the general welfare of its people authorizes it to prescribe all such regulations as, in its judgment, will secure or tend to secure them against the consequences of ignorance and incapacity as well as of deception and fraud.” Dent, 129 U. S., at 122; see also Watson v. Maryland, 218 U. S. 173, 176 (1910) (rejecting challenge to medical-licensing law).

 Today, every State has a medical-licensing scheme. See App. to Brief for Health Law Scholars as Amici Curiae. In practice, medical licensing serves two functions, both essential to patient safety. First, as the majority emphasizes, licensing sets limits on who may practice medicine. See P. Larkin, M. Fishpaw, & L. McCarthy, Telemedicine and Occupational Licensing, 73 Admin. L. Rev. 747, 774 (2021); ante, at 20. But the second function is more important for this case: State licensing laws also regulate how those professionals may practice, by requiring them to adhere to a standard of care. See Brief for Respondents 27; see also App. to id., at 1a–8a (listing state laws that require medical and mental health professionals to be licensed and to comply with professional standards).

 While licensing regulates medical professionals ex ante, medical-malpractice lawsuits enforce those standards ex post. And just like medical licensing, the tort of medical malpractice has a long pedigree.

 English common law held doctors liable for harm caused by their negligent medical treatment. 3 W. Blackstone, Commentaries on the Laws of England *122 (W. Lewis ed. 1922) (1768). The English tradition carried forward; this legal claim has been available in our country since the founding. See K. De Ville, Medical Malpractice in Nineteenth-Century America: Origins and Legacy 3, 5 (1990) (De Ville). In the mid-1800s, the number of malpractice cases skyrocketed, filling the void left by the States’ temporary deregulation of medical licensing. See id., at 25–34; see also id., at 115–137; Graham v. Gautier, 21 Tex. 111, 117–118 (1858) (observing that the lack of a licensing scheme demanded enforcement of a corresponding standard of care).

 Historically, the medical-malpractice tort generally required the plaintiff to prove three things: (1) that there was a professional-patient relationship, (2) that the medical professional had caused him harm, and (3) that the provider had departed from a standard of care. De Ville 46–50. The majority focuses on the requirement to show harm. Ante, at 21. But the entire point of the third element was to reinforce the standards that govern medical practitioners. For that reason, the harmed plaintiff was required to establish that the accused physician had not practiced with “ordinary care, diligence, and skill.” See De Ville 49 (emphasis deleted).

 State enforcement of the standard of care—i.e., “the care, skill, and knowledge regarded as competent among similar medical providers in the same or similar circumstances,” Restatement (Third) of Torts: Medical Malpractice §5 (Tent. Draft No. 2, Mar. 2024)—has continued over time and still serves as the touchstone for both licensing schemes and medical-malpractice lawsuits. Brief for Respondents 25–26, and App. to id., at 1a–8a. That is, States have consistently regulated medical professionals’ conduct to ensure that modern healthcare practices conform to the standard of care through both medical-malpractice law and professional licensing.

 Note, too, that such state regulation has not been limited to medical procedures: Physicians have historically been held liable for what they said when administering those procedures as well. See Graham, 21 Tex., at 119–120 (imposing liability for medical advice); Edwards v. Lamb, 69 N. H. 599, 45 A. 480 (1899); Skillings v. Allen, 143 Minn. 323, 173 N. W. 663 (1919). Moreover, in the past, States have—as part of their licensing regulations—defined the “practice of medicine” to cover practitioner speech. See, e.g., Smith v. People, 51 Colo. 270, 272, 117 P. 612, 613 (1911) (noting that the “practice of medicine” as regulated by Colorado’s licensing law included “suggestion[s or] recommendation[s] . . . of treatment”).

 In short, States have regulated professional conduct related to the provision of all kinds of medical care—and incidentally restricted speech—without constitutional affront for eons. Though the majority averts its gaze, even a cursory glance at the broader historical record is illuminating, for it reveals that States have traditionally played a significant role in setting the standards that govern the medical profession. See Washington v. Glucksberg, 521 U. S. 702, 731 (1997) (emphasizing the state interest “in protecting the integrity and ethics of the medical profession”); Barsky v. Board of Regents of Univ. of N. Y., 347 U. S. 442, 451 (1954) (same).

 With the MCTL, Colorado has merely taken up that same mantle. That law operates by prohibiting a particular medical treatment the State considers harmful, and nothing about it implicates Chiles’s First Amendment rights in a markedly different fashion than other States’ traditional efforts to regulate and enforce the standard of care.¹¹

 One more thought on this: The majority rigidly imposes a history-and-tradition test that treats the plethora of historical examples as insufficient. See ante, at 18–22. But it should instead find the long tradition of state laws setting standards of care by regulating the professional conduct of medical providers—including those who treat with speech—doubly reassuring.

 For one thing, this history helps us to be confident that what Colorado is doing here is actually regulating medical care, not suppressing messages. The record shows that States have routinely enacted laws that establish and enforce the standard of care, and that serves as a backdrop for an understanding of how States have acted historically to protect their residents from harm. The majority is right about one thing, however: A State will always say that its law just regulates the provision of medical treatments, while the challenger will inevitably argue that the State’s law nefariously targets speech qua speech. See ante, at 16. A lengthy tradition of similar regulatory efforts by States—or the absence of one—helps courts to ferret out who has the better of that argument.

 The history also helpfully demonstrates that a lower level of scrutiny is appropriate here, despite the impact of the MCTL on Chiles’s speech. We can rest easy, comforted by the fact that this law is not actually operating to suppress the expression of thoughts, messages, or ideas about conversion therapy; instead, the MCTL restricts talk therapists in the same way and to the same extent as other healthcare professionals have historically been limited when treating patients. Like other valid licensing restrictions, the MCTL does not prevent Chiles from speaking out in favor of conversion therapy, promoting conversion therapy, or otherwise lending credence to efforts to validate that therapy. All this law does is prohibit Chiles from providing this treatment to minor patients—no different than what Colorado and other States have been doing in the indisputably valid exercise of their police powers for centuries.¹²

 All things considered, then, I reach a different conclusion in this case than the majority does because precedent, principles, and history point in the same direction: No heightened scrutiny is warranted here. The First Amendment cares about government efforts to suppress “speech as speech” (based on its expressive content), not laws that, like the MCTL, restrict speech “incidentally,” due to the government’s traditional, garden-variety regulation of such speakers’ professional conduct.

IV

 Ultimately, 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. This decision might make speech-only therapies and other medical treatments involving practitioner speech effectively unregulatable—not to be reached via licensing standards, medical-malpractice liability, or any other means of state control. Who knows? Certainly not the majority. It appears to have made this momentous decision without adequately grappling with the potential long-term and disastrous implications of this ruling.

 The fallout could be catastrophic. Many regulations impact the speech of medical professionals in the context of their provision of healthcare to patients; the possibilities go far beyond talk therapy and informed consent. For example, many States require that medical professionals “make every reasonable effort to promote the welfare, autonomy and best interests of ” the client. Ga. Comp. Rules & Regs., Rule 135–7–.01(1) (2026); see Ind. Admin. Code, tit. 839, §1–§5–5(1) (2026); Conn. Gen. Stat. §17a–542 (requiring “[h]umane and dignified treatment”) (2025); Ala. Admin. Code Rule 255–X–11–.01 (Supp. 2016) (requiring that the professional “assure client welfare and protection” during medical care). Some States further prohibit medical professionals from treating a patient “in a cruel manner.” Kan. Admin. Regs. 102–3–12a(b)(11) (2022). Similarly, some licensing boards can discipline a provider who “is incompetent.” Alaska Stat. §08.29.400(4) (2025).¹³

 On the majority’s view, these kinds of regulations become unenforceable if the healthcare provider risks harming patients with their speech rather than an operation. Providers who offer “cruel” speech-only therapies or who use speech to (intentionally or incompetently) harm the welfare of patients, for example, can now assert a First Amendment right to carry on, regardless of these standards.

 So, to put it bluntly, the Court could be ushering in an era of unprofessional and unsafe medical care administered by effectively unsupervised healthcare providers. A state license used to mean something to the patients who entrust their care to licensed professionals—i.e., that the person is certified to be one who provides treatments that are consistent with the standard of care.

 That stops today. Indeed, it is not at all clear how, or to what extent, state regulation of medical care involving practitioner speech can survive this holding. We are on a slippery slope now: For the first time, the Supreme Court has interpreted the First Amendment to bless a risk of therapeutic harm to children by limiting the State’s ability to regulate medical providers who treat patients with speech. What’s next? In the worst-case scenario, our medical system unravels as various licensed healthcare professionals—talk therapists, psychiatrists, and presumably anyone else who claims to utilize speech when administering treatments to patients—start broadly wielding their newfound constitutional right to provide substandard medical care.

 It is baffling that we could now be standing on the edge of a precipitous drop in the quality of healthcare services in America. But the Court sees fit to bring us one step closer to that fate today. Stranger still is the fact that this possibility looms in the 21st century—given what science now enables us to know about medical conditions and treatments, what our cases say, and what we all should have learned by now from history. Somehow, Justices from eras past have always understood that (as I stated at the outset) “there is no right to practice medicine which is not subordinate to the police power of the States.” Lambert, 272 U. S., at 596. They correctly applied that simple but powerful understanding of our Constitution across the board—to all healthcare professionals, including those with practices that happen to involve treatment-related speech. We do harm to both the Nation’s medical system and our First Amendment jurisprudence by ignoring that wisdom today.

*  *  *

 The First Amendment requires heightened scrutiny when States regulate “speech as speech” but not when speech is restricted “incidentally.” NIFLA, 585 U. S., at 769–770. The latter occurs where, as here, a State seeks to prohibit healthcare professionals from providing a dangerous medical treatment in all of its forms, including the speech-related variety. States have traditionally regulated the provision of medical care through licensing schemes and malpractice regimes without constitutional incident. And no core principle of our First Amendment jurisprudence leads inexorably to the conclusion that it violates the Constitution for a State to prevent its licensed talk therapists from using speech to harm the minors in their care. Holding otherwise, as the majority does now, flouts centuries of state-standardized regulation of medical care and is, ultimately, nonsensical. The Constitution does not pose a barrier to reasonable regulation of harmful medical treatments just because substandard care comes via speech instead of scalpel.

 Accordingly, I cannot agree with the majority’s analysis or its conclusions in this case. The majority finds, at bottom, that Colorado likely cannot legislate to protect the children of its State if, by doing so, it happens to keep state-licensed healthcare providers from saying what they want to say to minors. And the majority’s holding means, in effect, that just because Chiles is a talk therapist—and not, say, a surgeon—a State can be prevented from incidentally imposing reasonable restrictions on the treatments she provides. Our precedents do not compel this conclusion. In fact, NIFLA draws a different line, and the correct course of action here is to hold it: Speech uttered for purposes of providing medical treatment may be restricted incidentally when the State reasonably regulates the speaker’s provision of medical treatments to patients. Id., at 769–770.

 To do anything else opens a dangerous can of worms. It threatens to impair States’ ability to regulate the provision of medical care in any respect. It extends the Constitution into uncharted territory in an utterly irrational fashion. And it ultimately risks grave harm to Americans’ health and wellbeing.