Supreme Court Decides United States v. Skrmetti

On June 18, 2025, the United States Supreme Court decided United States v. Skrmetti, No. 23-477, holding that Tennessee’s law prohibiting certain medical treatments for transgender minors is not subject to heightened scrutiny under the Fourteenth Amendment’s Equal Protection Clause and satisfies rational basis review.

In 2023, Tennessee adopted the Prohibition on Medical Procedures Performed on Minors Related to Sexual Identity, Senate Bill 1 (SB1), which in relevant part prohibits health care providers from prescribing, administering, or dispensing puberty blockers or hormones to any minor for the purpose of (1) enabling the minor to identify with, or live as, a purported identity inconsistent with the minor’s biological sex, or (2) treating purported discomfort or distress from a discordance between the minor’s biological sex and asserted identity.

Three transgender minors, their parents, and a doctor challenged SB1 under the Equal Protection Clause of the Fourteenth Amendment. The District Court partially enjoined SB1, finding that transgender individuals constitute a quasi-suspect class, that SB1 discriminates on the basis of sex and transgender status, and that SB1 was unlikely to survive intermediate scrutiny. The Sixth Circuit reversed, holding that the law did not trigger heightened scrutiny and satisfied rational basis review.

The Court first held that SB1 is not subject to heightened scrutiny because its classifications and application do not turn on sex. The Court found that SB1 incorporates two classifications: (1) age and (2) medical use. Classifications that turn on age or medical use, the Court noted, are subject to only rational basis review. Additionally, the Court found that application of SB1 does not turn on sex. The Court reasoned that SB1 prohibits administration of puberty blockers or hormones to any minor to treat gender dysphoria, gender identity disorder, or gender incongruence, regardless of the minor’s sex; conversely, it permits providers to administer puberty blockers and hormones to minors of any sex for other purposes.

The Court also held that SB1 does not classify on the basis of transgender status. The Court noted that it has held that a State does not trigger heightened constitutional scrutiny by regulating a medical procedure that only one sex can undergo unless the regulation is a mere pretext for invidious sex discrimination. SB1, the Court concluded, suffered from no such pretext. The Court reasoned that SB1 does not exclude any individual from medical treatments on the basis of transgender status. Rather, it removes one set of diagnoses — gender dysphoria, gender identity disorder, and gender incongruence — from the range of treatable conditions.

The Court declined to address whether its reasoning in Bostock v. Clayton County, 590 U.S. 644 (2020) reaches beyond the Title VII context. The Court explained that unlike the employment discrimination at issue in Bostock, hypothetically changing a minor’s sex or transgender status would not alter the application of SB1 and thus neither sex nor transgender status is the but-for cause of the inability to obtain the prohibited medical treatment.

Finally, applying rational basis review, the Court noted that Tennessee determined that administering puberty blockers or hormones to minors to treat gender dysphoria, gender identity disorder, or gender incongruence carries risks, including irreversible sterility, increased risk of disease and illness, and adverse psychological consequences, and that minors lack the maturity to fully understand these consequences. The Court held that SB1’s age- and diagnosis-based classifications are rationally related to those findings and the State’s objective of protecting minors’ health and welfare, and thus upheld the law.

Chief Justice Roberts delivered the opinion of the Court in which Justices Thomas, Gorsuch, Kavanaugh, and Barrett joined, and in which Justice Alito joined as to Parts I and II-B. 

Justice Thomas filed a concurring opinion. Justice Barrett filed a concurring opinion, in which Justice Thomas joined. Justice Alito filed an opinion concurring in part and concurring in the judgment. 

Justice Sotomayor filed a dissenting opinion, in which Justice Jackson joined in full, and in which Justice Kagan, joined as to Parts I–IV. Justice Kagan filed a dissenting opinion.