U.S. v. Skrmetti

Today, June 18, 2025, the Supreme Court released its decision in U.S. v. Skrmetti, a challenge to Tennessee Senate Bill 1, which prohibits healthcare providers from performing or administering gender-affirming care to minors while allowing the same treatments for minors who suffer from other conditions In the 6-3 opinion, written by Chief Justice Roberts, the Court upheld the law, concluding that the ban “is not subject to heightened scrutiny under the Equal Protection Clause of the Fourteenth Amendment and satisfies rational basis review.”

What You Need to Know

• Facts of the Case: At least 26 states have banned gender-affirming healthcare for people under 18 years old in the past four years, despite it being available and the standard of care for decades. Passed in 2023, Tennessee’s ban applies to both medication and surgical care for transgender youth, characterized by the state as: “(A) Enabling a minor to identify with, or live as, a purported identity inconsistent with the minor's sex; or (B) Treating purported discomfort or distress from a discordance between the minor's sex and asserted identity.” Tennessee’s ban states that: “These procedures can lead to the minor becoming irreversibly sterile, having increased risk of disease and illness, or suffering from adverse and sometimes fatal psychological consequences. Moreover, the legislature finds it likely that not all harmful effects associated with these types of medical procedures when performed on a minor are yet fully known, as many of these procedures, when performed on a minor for such purposes, are experimental in nature and not supported by high-quality, long-term medical studies.” Despite these purported concerns, the state prohibits these treatments only for one use — gender-affirming healthcare. The ban explicitly allows the same treatments to be provided for minors suffering from any other medical conditions for which such treatment, including puberty blockers, hormone therapy, or surgery, is considered the standard of care. This disparate treatment was one of the bases for the challenge of the ban under the Equal Protection Clause of the Fourteenth Amendment.

• Question Presented: Whether Tennessee Senate Bill 1, which prohibits all medical treatments intended to allow “a minor to identify with, or live as, a purported identity inconsistent with the minor’s sex” or to treat “purported discomfort or distress from a discordance between the minor’s sex and asserted identity,” violates the Equal Protection Clause of the Fourteenth Amendment.

• Oral Argument: When this case was argued before the Court last October, then-U.S. Solicitor General Elizabeth Prelogar and ACLU’s Co-Director of the LGBT & HIV Project Chase Strangio (who is the first openly transgender attorney to appear before the U.S. Supreme Court), argued that the Court should find that SB 1 makes a sex-based classification subject to intermediate scrutiny under the Equal Protection Clause, recognize transgender status as a suspect classification entitled to similar heightened scrutiny, or hold that SB 1 does not withstand even rational basis review. Tennessee argued that the ban should be subject rational basis review, denying that SB 1 makes a sex-based classification or that transgender status is a suspect classification under the Constitution.
• The Court’s Decision: In a 6-3 decision written by Chief Justice Roberts, the Court held that SB 1 makes only two classifications: age (minor v. adult) and medical use (gender affirming care v. all other uses) and that neither of those classifications triggers the need for heightened scrutiny. The majority fails to adequately address the argument made on behalf of the plaintiffs that the law draws a clear classification based on sex, given that “a teenager whose sex assigned at birth is male can be prescribed testosterone to conform to a male gender identity, but a teenager assigned female at birth cannot.” Rather, the Court’s majority opinion contends that the sex classification explicitly included in the law is a “mere reference,” that is not sufficient to trigger heightened scrutiny. The Court further denies what is plainly clear in this and other similar bans, that the targeted group for these laws are transgender people. In a particularly galling assertion, Chief Justice Roberts states that the bans do not single out transgender people but rather, “remove[] one set of diagnoses—gender dysphoria, gender identity disorder, and gender incongruence—from the range of treatable conditions.” This assertion studiously ignores that fact that these diagnoses are the medical bases for gender confirming treatments almost exclusively sought after by one group—transgender and gender nonconforming people. Finally, in rejecting the plaintiff’s argument that SB 1 and similar bans fail even under the most permissive standard of review—rational basis—the Court again willfully ignores the animus and discriminatory intent of the ban on gender confirming healthcare. The Court relied on the states unsupported claims of increased risk of disease and adverse psychological consequences, despite an amicus brief from the American Academy of Pediatrics, joined by more than a dozen other medical and mental health organizations, asserting that, “Empirical evidence indicates that gender-affirming care, including the prescription of puberty blockers and hormone therapy . . . can alleviate clinically significant distress and lead to significant improvements in the mental health and overall wellbeing of adolescents with gender dysphoria.”
• The Dissent: In her dissent, Justice Sotomayor, joined by Justices Jackson and Kagan, makes clear the incongruity of the majority’s opinion, observing that under SB 1, “Male (but not female) adolescents can receive medicines that help them look like boys, and female (but not male) adolescents can receive medicines that help them look like girls,” making it a clear sex classification based on sex. She continues, “The majority contorts logic and precedent to say otherwise, inexplicably declaring it must uphold Tennessee’s categorical ban on lifesaving medical treatment so long as “‘any reasonably conceivable state of facts’” might justify it.” She concludes that the Court’s decision to obsfucate the obvious sex classification inherent in SB 1 “does irrevocable damage to the Equal Protection Clause and invites legislatures to engage in discrimination by hiding blatant sex classifications in plain sight. It also authorizes, without second thought, untold harm to transgender children and the parents and families who love them.
• The Potential Impact: According to the Williams Institute, nearly 40 percent of trans youth ages 13-17 live in a state where they are denied potentially lifesaving medical treatment due to bans similar to SB 1. By allowing Tennessee’s ban to remain in place, the Court is making this critical healthcare unavailable to thousands of young people seeking to express their authentic identities. Much like reproductive healthcare post-Dobbs, this decision creates an unnecessary and harmful divide making critical healthcare contingent on the state in which one lives. The Court’s decision may also serve as a signal to states seeking to pass even more draconian bans targeted at both youth and adults. In fact, during oral argument, Strangio noted that if this ban were upheld in the face of an equal protection challenge, then bans of gender-affirming healthcare for adults might also be constitutionally permitted, a position Tennessee Solicitor General Matthew Rice said the state would take.

Oral Argument

On December 4, 2024, the Supreme Court heard oral argument in U.S. v. Skrmetti, a challenge under the Equal Protection Clause to Tennessee Senate Bill 1, which prohibits healthcare providers from performing or administering gender-affirming care to minors while allowing the same treatments for minors who suffer from “congenital defect, precocious puberty, disease, or physical injury.” This is the first case the Court has heard related to a ban on gender-affirming care for people under 18 years old, of which 26 states currently have some form.

What You Need to Know

• Facts of the Case: Since 2021, at least 26 states have banned gender-affirming healthcare for people under 18 years old, despite such healthcare being available and the standard of care for decades. Two states ban best practice surgical care for transgender youth, while the remaining 24 states ban both best practice medication and surgical care for transgender youth. Passed in 2023, Tennessee’s ban applies to both medication and surgical care for transgender youth, characterized by the state as: “(A) Enabling a minor to identify with, or live as, a purported identity inconsistent with the minor's sex; or (B) Treating purported discomfort or distress from a discordance between the minor's sex and asserted identity.” The ban creates a private right of action for minors and their parents or next of kin against a healthcare provider who provided gender-affirming care and allows the state attorney general to independently seek civil penalties of $25,000 per violation of the ban. The ban explicitly allows the same treatments to be provided for minors suffering from any other medical conditions for which such treatment, including puberty blockers, hormone therapy, or surgery, is considered the standard of care. Tennessee’s ban states that: “These procedures can lead to the minor becoming irreversibly sterile, having increased risk of disease and illness, or suffering from adverse and sometimes fatal psychological consequences. Moreover, the legislature finds it likely that not all harmful effects associated with these types of medical procedures when performed on a minor are yet fully known, as many of these procedures, when performed on a minor for such purposes, are experimental in nature and not supported by high-quality, long-term medical studies.” Despite these purported concerns, the state prohibits these treatments only for one use — gender-affirming healthcare. Yet, in an amicus brief filed with the Court, the American Academy of Pediatrics, joined by more than a dozen other medical and mental health organizations, asserted that, “Empirical evidence indicates that gender-affirming care, including the prescription of puberty blockers and hormone therapy . . . can alleviate clinically significant distress and lead to significant improvements in the mental health and overall wellbeing of adolescents with gender dysphoria.”

• Procedural History: In 2023, three transgender minors, their parents, and a doctor sued several Tennessee officials in the U.S. District Court for the Middle District of Tennessee. The U.S. Department of Justice intervened to support the plaintiffs under a federal law that permits the Attorney General to sue to address equal protection violations. The district court judge found that that the ban “discriminates on the basis of sex and that transgender persons constitute a quasi-suspect class” and was therefore “facially unconstitutional,” and issued a preliminary injunction. The U.S. Court of Appeals for the Sixth Circuit overturned the judge’s decision in the case and stayed the injunction, allowing the ban to go into effect. The Supreme Court granted certiorari in June 2024.

• Questions Presented: Whether Tennessee Senate Bill 1, which prohibits all medical treatments intended to allow “a minor to identify with, or live as, a purported identity inconsistent with the minor’s sex” or to treat “purported discomfort or distress from a discordance between the minor’s sex and asserted identity,” violates the Equal Protection Clause of the 14th Amendment.

• What Happened at Oral Argument: Both U.S. Solicitor General Elizabeth Prelogar, and counsel for the three transgender minors, Co-Director of the ACLU’s LGBT & HIV Project Chase Strangio (whose appearance marked the first time an openly transgender attorney appeared before the U.S. Supreme Court), argued that the Court should find that SB 1 makes a sex-based classification subject to intermediate scrutiny under the Equal Protection Clause, recognize transgender status as a suspect classification entitled to similar heightened scrutiny, or hold that SB 1 does not withstand even rational basis review. Applying heightened scrutiny based on sex or transgender status would require Tennessee (and other states imposing similar bans) to demonstrate that the law furthers an important government interest and that the means are substantially related to that interest. As Prelogar noted, the challenged law would not survive heightened scrutiny in part because it is underinclusive. Despite the state’s claim that puberty blockers and hormone treatments are too dangerous to adolescent health, those treatments are allowed for all medical purposes except when a minor seeks to affirm their gender identity in contrast to the gender they were assigned at birth. “Thus, for example, a teenager whose sex assigned at birth is male can be prescribed testosterone to conform to a male gender identity, but a teenager assigned female at birth cannot.” Tennessee makes this classification explicit by justifying SB 1 as “encouraging minors to appreciate and not be disdainful of their sex.” Justice Alito expressed skepticism about the medical validity of gender-affirming healthcare and at various points attempted to include evidence that had neither been admitted in the original district court case or otherwise briefed, leading Prelogar to respond that, “There is a time and place for that inquiry. It’s not here.” She argued that the Court’s role in this case is to determine the level of scrutiny and remand to the district court to figure out the factual record. Justice Alito, along with Justices Kavanaugh, Thomas, and Chief Justice Roberts, expressed concern about the Court’s role in evaluating such medical evidence and each suggested that it may be outside the Court’s proper role. This prompted Justice Jackson to express concern, saying “It is a bedrock in the Equal Protection framework that . . . where a legislature is drawing lines [using] suspect classifications . . . that’s a question for the Court.” She expressed concern that any suggestion that the Court should step away from that role will “[u]ndermine the foundational bedrock of equal protection.”

• Potential Impact: Three circuits courts have allowed gender-affirming healthcare bans enacted by multiple states to go into effect. These bans have proliferated and now, according to the Williams Institute, nearly 40 percent of trans youth ages 13-17 live in a state where they are denied potentially lifesaving medical treatment. If the Court upholds the ban in this case, it would remain in effect in Tennessee and would impact challenges to other states’ bans in courts throughout the country. It could also lead more states to pass these and even more draconian bans. During oral argument, Strangio noted that if this ban were upheld in the face of an equal protection challenge, then bans of gender-affirming healthcare for adults might also be constitutionally permitted, a position Tennessee Solicitor General Matthew Rice said the state would take.

For more information about the cases on the Court’s docket this term, make sure to listen to our Broken Law podcast (Episode 158 is our SCOTUS Preview) and catch the video of our SCOTUS Preview program.