United States v. Skrmetti, Docket No. 23-477
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With a sharp focus on where law meets medicine, the Supreme Court upheld Tennessee’s ban on puberty blockers and hormones for minors seeking care for gender dysphoria or to live as a gender different from their birth sex. The justices said this law doesn’t single out transgender kids but sets rules based on age and medical treatment. Chief Justice Roberts wrote that, in situations where scientists and doctors still debate, courts should give room for states to protect young people’s health.
Several justices added separate notes to explain parts of their agreement, while Justices Sotomayor and Kagan issued a strong dissent, warning that this ban risks harming vulnerable children and cutting off their access to care.
Summary of the Case
In 2023, Tennessee passed a law called SB1, which prohibits healthcare providers from giving puberty blockers or hormones to minors for gender-affirming care. The law specifically bans these treatments when used to help minors identify with a gender different from their birth sex or to treat distress from gender incongruence. However, the same medications remain available for adults and for minors with other medical conditions like precocious puberty or certain diseases.
Three transgender minors, their parents, and a physician challenged the law as unconstitutional under the Equal Protection Clause, and the U.S. government joined their case. Initially, a federal district court blocked the law, ruling that it discriminated based on sex and transgender status. However, the Sixth Circuit Court of Appeals reversed this decision, accepting Tennessee's argument that medical uncertainty provided a rational basis for the law.
The Supreme Court then took up the case to determine whether Tennessee's law violates equal protection rights.
How the Supreme Court Ruled on Gender-Affirming Care Restrictions
In a 5-4 decision, the Supreme Court upheld Tennessee's law. Chief Justice Roberts wrote the majority opinion, joined by Justices Thomas, Gorsuch, Kavanaugh, Barrett, and partially by Justice Alito.
The majority ruled that the law doesn't trigger heightened scrutiny because it classifies people based on two non-suspect grounds: age (adults versus minors) and medical purpose (gender dysphoria treatment versus other medical conditions). The Court determined that the law doesn't discriminate based on sex or transgender status.
According to the majority, merely referring to sex in defining a medical procedure doesn't automatically require intermediate scrutiny. They found that the law applies equally to all minors regardless of sex and doesn't reveal any discriminatory intent.
The Court also rejected the argument that the law classifies based on transgender status, stating that it excludes certain diagnoses from covered medical conditions rather than targeting transgender people themselves. The majority distinguished this case from Bostock v. Clayton County (an employment discrimination case), saying that changing a patient's sex wouldn't alter how the law operates since it focuses on diagnosis, not identity.
Under the less stringent rational-basis review, the Court found that Tennessee's concerns about medical risks, minors' maturity, potential regret, and alternative treatments provided sufficient justification for the law's restrictions.
Separate Opinions
Several justices wrote separate opinions:
Justice Thomas concurred but declined to extend the reasoning from Bostock beyond employment discrimination cases. He also warned against excessive deference to medical experts in constitutional cases.
Justice Barrett agreed that transgender status is not a suspect class warranting heightened scrutiny.
Justice Alito joined parts of the majority opinion but wrote separately to say he would have upheld the law even under heightened scrutiny.
In dissent, Justice Sotomayor (joined by Justices Jackson and Kagan) argued that the law clearly classifies based on sex and transgender status because it allows these medications only when they align with birth sex. She contended that intermediate scrutiny should apply, and under that standard, Tennessee failed to show its ban was substantially related to protecting minors' health.
Justice Kagan wrote a separate dissent (joined by Justices Jackson and Sotomayor) agreeing that intermediate scrutiny should apply.
The Medical and Legal Debate Behind Gender-Affirming Care Bans
Tennessee's law reflects the legislature's concerns about the growing use of puberty blockers and hormones for treating gender dysphoria in minors. The state cited worries about potential irreversible effects, including sterility, health risks, and psychological consequences. The law also referenced minors' limited capacity to fully understand long-term outcomes and reports of regret.
The law makes a critical distinction: it permits these medications for traditional medical conditions but prohibits them when used to facilitate gender identity different from birth sex or to treat distress related to gender dysphoria.
The dissenting justices argued that this distinction itself reveals the sex-based nature of the law, as the same treatment is allowed or banned depending on whether it preserves or challenges birth sex alignment. This fundamental disagreement about how to classify the law's restrictions formed the core of the Court's split decision.