United States v. Skrmetti
605 U. S. ____ (2025) (2025)
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Rule of Law:
A state law prohibiting certain medical treatments like puberty blockers and hormones for minors for gender-transition purposes, while permitting them for other medical conditions, does not create a classification based on sex or transgender status that would trigger heightened scrutiny and is constitutional if it satisfies rational basis review.
Facts:
- In 2023, Tennessee enacted Senate Bill 1 (SB1), a law regulating medical procedures for minors.
- SB1 prohibits healthcare providers from prescribing or administering puberty blockers or hormones to a minor for the purpose of enabling the minor to identify with an identity inconsistent with their biological sex.
- The law also prohibits these treatments for addressing a minor's discomfort or distress arising from a discordance between their biological sex and asserted gender identity.
- SB1 explicitly permits healthcare providers to administer the exact same puberty blockers or hormones to minors to treat other conditions, such as a congenital defect, disease, physical injury, or precocious puberty.
- The law specifically excludes 'gender dysphoria, gender identity disorder, [and] gender incongruence' from the definitions of conditions like 'disease' that would otherwise permit treatment.
- Three transgender minors were receiving or seeking to receive puberty blockers or hormone therapy for gender dysphoria, and SB1 prohibited them and their doctor from continuing or starting this course of treatment.
Procedural Posture:
- Three transgender minors, their parents, and a doctor sued Tennessee officials in the U.S. District Court for the Middle District of Tennessee, challenging SB1 as a violation of the Equal Protection Clause.
- The United States intervened in the lawsuit on behalf of the plaintiffs.
- The plaintiffs moved for a preliminary injunction to prevent enforcement of the law's prohibitions on puberty blockers and hormones.
- The District Court granted a partial preliminary injunction, concluding the plaintiffs were likely to succeed on their claim that the law unconstitutionally discriminates based on sex and transgender status.
- Tennessee (defendants/appellants) appealed the injunction to the U.S. Court of Appeals for the Sixth Circuit.
- The Sixth Circuit stayed the injunction and subsequently reversed the District Court, holding that the law was subject to rational basis review, not heightened scrutiny, and was likely constitutional.
- The Supreme Court of the United States granted the United States' petition for a writ of certiorari to review the Sixth Circuit's decision.
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Issue:
Does Tennessee's law, which prohibits healthcare providers from administering puberty blockers or hormones to minors for the purpose of gender transition but permits them for other medical reasons, violate the Equal Protection Clause of the Fourteenth Amendment?
Opinions:
Majority - Chief Justice Roberts
No, Tennessee's law does not violate the Equal Protection Clause. The law is not subject to heightened scrutiny because its classifications are based on age and medical use, not sex or transgender status, and it satisfies rational basis review. The law does not classify on the basis of sex because it prohibits these treatments for a specific purpose for all minors, regardless of their sex. The proper understanding of a 'medical treatment' includes both the drug and its indication; therefore, administering testosterone to a transgender boy for gender dysphoria is a different treatment than administering it to a cisgender boy for precocious puberty. The law also does not classify based on transgender status, following the reasoning of Geduldig v. Aiello, because it removes a set of diagnoses (gender dysphoria) from the list of treatable conditions rather than targeting a class of people. Finally, the law survives rational basis review because Tennessee's stated interests in protecting minors from what it found to be irreversible and uncertain medical treatments provide a reasonably conceivable basis for the legislation, especially in an area of ongoing medical and scientific debate.
Concurring - Justice Thomas
Yes, I agree with the Court that the law is constitutional. The reasoning from Bostock v. Clayton County, a Title VII case, should not be imported into the Equal Protection Clause analysis. Courts should not defer to a purported expert consensus on controversial medical issues, especially when there is significant international debate and evolving evidence regarding the risks of these treatments. The American people and their elected representatives, not medical associations or courts, are entitled to make policy judgments in areas of scientific uncertainty.
Concurring - Justice Barrett
Yes, I agree with the Court that the law is constitutional. I write separately to explain why transgender status does not constitute a suspect or quasi-suspect class warranting heightened scrutiny. Transgender status does not involve an 'obvious, immutable, or distinguishing characteristic' because it is not fixed at birth and the group is amorphous. Furthermore, for purposes of the suspect class inquiry, the relevant history of discrimination is de jure (in law), not merely private discrimination, and it is not clear that such a history exists for transgender people. Recognizing transgender status as a suspect class would improperly involve courts in overseeing numerous policy choices best left to legislatures.
Concurring - Justice Alito
Yes, I agree the law is constitutional, but for different reasons regarding the classification. While SB1 does not classify based on sex, there is a strong argument that it does classify based on transgender status. However, instead of avoiding that question, I would assume it does and hold that transgender status is not a suspect or quasi-suspect class. Therefore, the law is still subject only to rational basis review, which it satisfies for the reasons the Court states.
Dissenting - Justice Sotomayor
Yes, Tennessee's law violates the Equal Protection Clause. The law plainly classifies based on sex and transgender status, requiring the application of intermediate scrutiny. Its application turns on sex: it permits treatments that help a minor conform to their sex assigned at birth but prohibits the very same treatments if they help a minor live in a way that is inconsistent with their sex. For example, a doctor can prescribe medication to a female patient to reduce unwanted facial hair but cannot prescribe the same medication to a male patient (a transgender girl) for the same purpose. By recasting this clear sex-based line as a neutral classification of 'medical use,' the majority contorts precedent and logic. The Court abdicates its duty to protect a vulnerable minority and allows discrimination to hide in plain sight.
Dissenting - Justice Kagan
Yes, I agree with the dissent that the law warrants heightened scrutiny because it classifies based on sex. I would not decide how SB1 would fare under that scrutiny. Because the Court of Appeals failed to apply the correct standard of review, the proper course is to remand the case for the lower courts to apply heightened scrutiny in the first instance, as the parties requested.
Analysis:
This decision significantly narrows the application of heightened scrutiny under the Equal Protection Clause in the context of laws regulating gender-affirming care. By framing the legal classification as one of 'medical use' rather than sex or transgender status, the Court makes it substantially easier for states to defend such bans, requiring only a rational basis. The ruling also confines the 'but-for' causation analysis from Bostock v. Clayton County to its statutory Title VII context, preventing its direct application to constitutional equal protection claims. This precedent signals a strong judicial deference to legislative judgments in areas of scientific uncertainty and a reluctance to recognize new suspect or quasi-suspect classes.
