The conservative Supreme Court dealt a significant blow to transgender Americans on Wednesday, issuing a sweeping decision that may have implications beyond the medical care that was at center of one of the court’s highest-profile disputes this year.

The U.S. Supreme Court has upheld Tennessee’s ban on gender-affirming surgery for transgender youth in a ruling that’s likely to reverberate across the country. Most Republican-controlled states already have similar bans.

The decision to uphold the Tennessee law will most likely mean a patchwork of laws throughout the country, a map that traces current political polarization.