SCOTUS Upholds Tennessee Law Banning Gender Affirming Care for Minors

On June 18, 2025, the United States Supreme Court issued its decision in United States v. Skrmetti, a landmark case addressing the constitutionality of Tennessee’s Senate Bill 1 (SB1). This law, enacted in 2023, prohibits gender-affirming medical treatments, such as puberty blockers and hormone therapy, for minors when prescribed to treat gender dysphoria or to enable identification with a gender inconsistent with their sex assigned at birth. The case, which has drawn significant attention for its implications on transgender rights and healthcare access, was decided by a 6-3 vote, with the majority upholding the law.

Background of the Case

United States v. Skrmetti arose from a challenge to Tennessee’s SB1, which bans certain medical treatments for transgender minors while allowing similar treatments for cisgender minors in other medical contexts (e.g., for precocious puberty). The plaintiffs, including the United States (under the Biden Administration), three transgender youth, their families, and a Tennessee physician, argued that SB1 violates the Equal Protection Clause of the Fourteenth Amendment by discriminating based on sex and transgender status. The case reached the Supreme Court after the Sixth Circuit Court of Appeals upheld the law. Oral arguments were heard on December 4, 2024, and the decision was released on June 18, 2025.

The central legal question was whether SB1’s restrictions constitute discrimination under the Equal Protection Clause and, if so, what level of scrutiny should apply. The Equal Protection Clause requires that laws treat similarly situated individuals equally, with courts applying different levels of scrutiny depending on the classification involved: such as, strict scrutiny for race, intermediate scrutiny for sex, and rational basis review for most other classifications.

Majority Opinion

The majority opinion, authored by Chief Justice John Roberts and joined by Justices Clarence Thomas, Neil Gorsuch, Brett Kavanaugh, Amy Coney Barrett, and Samuel Alito (for Parts I and II–B), held that SB1 does not trigger heightened scrutiny under the Equal Protection Clause and satisfies rational basis review. The Court’s reasoning can be broken down into several key points:

The majority determined that SB1’s classifications are based on age (minors vs. adults) and the medical purpose of the treatment (e.g., treating gender dysphoria vs. other conditions), rather than sex or transgender status. The law applies uniformly to all minors, regardless of their sex or gender identity, and restricts treatments only when used for specific purposes related to gender dysphoria. As a result, the Court concluded that SB1 does not involve a suspect classification, such as sex, that would require intermediate scrutiny.

Application of Rational Basis Review

Because SB1 does not classify based on sex or transgender status, the majority applied rational basis review, the most deferential standard of constitutional scrutiny. Under this standard, a law is upheld if it is rationally related to a legitimate government interest. The Court found that Tennessee’s stated interest in protecting minors’ health was legitimate, citing legislative findings and international concerns about the long-term effects of gender-affirming treatments on minors. The majority emphasized that rational basis review does not require the law to be perfect or based on conclusive evidence, only that there is a “reasonably conceivable state of facts” supporting the classification.

Rejection of Sex Discrimination Arguments

The plaintiffs argued that SB1 discriminates based on sex, relying on precedents like Bostock v. Clayton County, which held that discrimination based on transgender status is a form of sex discrimination in the employment context. The majority rejected this analogy, noting that Bostock applied to Title VII, a statutory framework, whereas Skrmetti involves constitutional equal protection. The Court further argued that SB1’s restrictions do not depend on an individual’s sex assigned at birth but on the purpose of the treatment, thus avoiding sex-based classification.

The majority affirmed the Sixth Circuit’s judgment, upholding SB1 as constitutional. The Court’s decision allows Tennessee to enforce its ban on gender-affirming care for minors, provided the treatments are sought to treat gender dysphoria or enable gender transition.

Dissenting Opinions

The dissenting opinions, led by Justice Sonia Sotomayor and joined by Justices Ketanji Brown Jackson and Elena Kagan (in parts), sharply criticized the majority’s approach, arguing that SB1 discriminates based on sex and transgender status and warrants heightened scrutiny. The dissents highlighted the severe consequences of the law for transgender youth and accused the majority of undermining equal protection principles.

Justice Sotomayor’s Dissent

Justice Sotomayor, joined by Justice Jackson in full and Justice Kagan for Parts I–IV, argued that SB1 explicitly classifies based on sex and transgender status, requiring intermediate scrutiny. Her dissent made the following key points:

• Sex-Based Discrimination: Sotomayor contended that SB1 conditions access to treatments like hormones and puberty blockers on an individual’s sex assigned at birth. For example, a transgender girl (assigned male at birth) is denied hormone therapy to align with her gender identity, while a cisgender girl (assigned female at birth) may receive similar treatments for other medical conditions. This differential treatment, she argued, constitutes sex-based discrimination under precedents like Sessions v. Morales-Santana and United States v. Virginia.

• Transgender Status Discrimination: The dissent also asserted that SB1 targets transgender minors specifically, as it prohibits treatments only when used to treat gender dysphoria, a condition primarily affecting transgender individuals. Sotomayor argued that discrimination based on transgender status is inherently tied to sex, reinforcing the need for heightened scrutiny.

• Harm to Transgender Youth: Sotomayor emphasized the severe consequences of denying gender-affirming care, citing evidence that such treatments can be lifesaving for transgender youth. She referenced cases like those of plaintiffs Ryan Roe and L.W., who faced increased risks of depression, anxiety, and suicide due to the ban. The dissent criticized the majority for ignoring these harms and applying a deferential standard that fails to protect vulnerable minors.

• Critique of the Majority: Sotomayor accused the majority of causing “irrevocable damage to the Equal Protection Clause” by refusing to apply intermediate scrutiny. She argued that the Court’s decision “abandons transgender children” and sets a dangerous precedent for equal protection challenges involving transgender rights.

Justice Kagan’s Separate Dissent

Justice Kagan, while joining Parts I–IV of Sotomayor’s dissent, filed a separate opinion to express her view that SB1 warrants heightened scrutiny but that the case should be remanded to the lower courts for further review. Kagan agreed that SB1’s classifications are based on sex and transgender status, citing United States v. Virginia as a relevant precedent. However, she refrained from deciding whether SB1 would survive intermediate scrutiny, arguing that the Court should allow lower courts to develop a more comprehensive record on the law’s impact and justification. Kagan’s dissent reflects a cautious approach, emphasizing the need for thorough judicial review in complex cases involving sensitive issues.

Impact on Transgender Youth

By upholding SB1, the Court has effectively allowed Tennessee to restrict access to gender-affirming care for transgender minors, potentially affecting over one-third of transgender youth in the U.S., as Tennessee is one of 24 states with similar bans. Advocacy groups, such as Lambda Legal and the ACLU, have expressed concern that the ruling will exacerbate mental health challenges for transgender youth, who may face increased risks of depression, anxiety, and suicide without access to medically necessary care (Lambda Legal).

Precedent for Other States

The decision may embolden other states to enact or maintain similar bans on gender-affirming care. Legal experts predict that the ruling could influence not only transgender healthcare but also other areas of sex-based civil rights, including abortion access and protections for LGBTQ+ individuals. The majority’s use of rational basis review sets a low bar for states to justify such laws, potentially limiting the success of future equal protection challenges.

Broader Legal and Societal Debate

The ruling highlights the ongoing societal divide over transgender rights and the role of government in regulating medical decisions for minors. Supporters of SB1 argue that it protects young people from making irreversible medical choices before they are fully informed, while critics contend that it infringes on parental rights and denies transgender youth access to evidence-based care. The dissenting opinions, particularly Sotomayor’s, frame the issue as a matter of life and equality, underscoring the human stakes involved.

Future Legal Challenges

While the Court upheld SB1 under rational basis review, the dissents suggest alternative legal strategies, such as challenging similar laws on grounds of parental rights or substantive due process. Additionally, the change in the Department of Justice’s stance under the Trump administration, which argued in February 2025 that SB1 does not violate equal protection, may influence future federal litigation. Legal advocates, including the ACLU and Lambda Legal, have vowed to continue fighting such bans.

United States v. Skrmetti represents a pivotal moment in the legal and social discourse surrounding transgender rights in the United States. The Supreme Court’s 6-3 decision to uphold Tennessee’s ban on gender-affirming care for minors reflects a conservative approach to equal protection, prioritizing state authority over individual rights in this context. The majority’s application of rational basis review contrasts sharply with the dissents’ call for heightened scrutiny, revealing deep divisions within the Court and society at large.

As the nation grapples with these issues, the ruling is likely to shape future policies, legal challenges, and public debates over transgender healthcare and equality. The dissenting opinions, with their focus on the human cost of the law, serve as a reminder of the stakes for transgender youth and their families. Whether this decision marks a lasting shift in equal protection jurisprudence or prompts new avenues for advocacy remains to be seen.

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