On June 18, 2025, in a decision with multiple concurrences and dissents, the U.S. Supreme Court held that Tennessee’s SB1, which prohibits the provision of gender-affirming care to minors, does not violate the Equal Protection Clause of the Fourteenth Amendment. United States v. Skrmetti, No. 23-477, 605 U.S. ___ (June 18, 2025). This decision will have broad implications for gender-affirming care throughout the United States, given the Supreme Court’s holding that SB1 classifies based on age and medical condition, rather than sex, resulting in the Court’s application of rational basis review instead of heightened scrutiny.

Background on SB1

SB1 prohibits the use of certain medical procedures for treating transgender children under the age of 18. The law, passed in 2023, prohibits health care providers from performing surgical procedures and prescribing, administering, or dispensing puberty blockers and hormones for the purposes of (1) “[e]nabling a minor to identify with, or live as, a purported identity inconsistent with the minor’s sex,” or (2) “[t]reating purported discomfort or distress from a discordance between the minor’s sex and asserted identity.” Tenn. Code Ann. § 68-33-103(a)(1).

The law authorizes Tennessee’s attorney general to enforce SB1 by bringing actions against individuals who violate its provisions, permits the relevant state regulatory authorities to discipline health care providers who violate the law’s prohibitions, and creates a private right of action enabling an injured minor or nonconsenting parent of an injured minor to sue a health care provider for violating the law.

Tennessee is one of 27 states (at present) that have restricted gender-affirming care in some form. Twenty-five states have enacted laws that restrict providers from prescribing puberty blockers and hormones to minors, and two states have enacted bans against only gender-affirming surgical procedures for minors.

Circuit Split Prior to Skrmetti

Prior to the Supreme Court’s decision in Skrmetti, the Circuit Courts to have addressed this question were split as to whether laws prohibiting the provision of gender-affirming care to minors violate the Equal Protection Clause, among other constitutional rights. In short, the Sixth and Eleventh Circuits applied the less stringent rational basis review to uphold the Tennessee and Alabama laws banning gender-affirming care for minors, while the Eighth Circuit found that a similar Arkansas law discriminated on the basis of sex and thus was subject to review under the intermediate scrutiny standard.  In applying that standard, the Eighth Circuit struck down the Arkansas law.  Each is discussed in greater detail below.

In L.W. v. Skrmetti, 73 F.4th 408 (6th Cir. 2023)––the precursor decision to this week’s Supreme Court ruling––the Sixth Circuit reversed the lower court’s ruling, which had concluded that SB1, the Tennessee law prohibiting gender-affirming care for minors, violated the Equal Protection and Due Process Clauses. The Sixth Circuit applied rational basis review and concluded that the law was rationally related to the state’s legitimate interest in protecting minors. Under the Biden Administration, the federal government joined the suit and argued that the law violates the Equal Protection Clause. The case was eventually recaptioned United States v. Skrmetti.

In Eknes-Tucker v. Governor of the State of Alabama, 80 F.4th 1205 (11th Cir. 2023), the Eleventh Circuit upheld an Alabama law prohibiting various gender-affirming care treatments on the grounds that the law does not violate the Equal Protection Clause. The Eleventh Circuit noted that although the statute uses sex-related language, it does not classify based on sex. Rather, the court reasoned, the law regulates drugs that “treat a discordance between an individual’s sex and sense of gender identity.” Eknes-Tucker,  80 F.4th at 1235. Therefore, the court applied rational basis review in concluding that the law was constitutional.

In Brandt v. Rutledge, 47 F.4th 661 (8th Cir. 2022), the Eighth Circuit upheld an injunction against Arkansas’s law prohibiting health care professionals from providing gender-affirming care to individuals under the age of 18. In doing so, the Eighth Circuit determined that the law discriminated on the basis of sex because medical procedures permitted for a minor of one sex would be prohibited for a minor of another sex. The Court went on to note that “the minor’s sex at birth determines whether or not the minor can receive certain types of medical care under the law.” Brandt, 47 F.4th at 669. Thus, the Court subjected the law to intermediate scrutiny and determined that it violated the Equal Protection Clause.

The Supreme Court has now resolved this split, siding with the Sixth (and Eleventh) Circuit’s interpretations and paving the way for states like Arkansas to enforce laws prohibiting gender-affirming care for minors.

The Supreme Court’s Decision

Majority Opinion

The majority opinion, authored by Chief Justice Roberts and joined by Justices Thomas, Gorsuch, Kavanaugh, and Barrett in full, and in part by Justice Alito, held that SB1 is subject only to rational basis review because the law does not classify on any bases that warrant heightened review. Plaintiffs had argued the law classifies on the basis of sex because its prohibitions reference sex and application of the law turns on sex, which would subject the law to heightened scrutiny.

Unpersuaded by these arguments, the majority found instead that SB1 classifies on the basis of age—it prohibits the treatments for individuals under the age of 18—and “medical use“—the treatments are only prohibited for minors to treat gender dysphoria, gender identity disorder, and gender incongruence. Skrmetti, slip op. at 16. In other words, eligibility to receive the medical treatments is not conditioned upon a person’s sex; rather, eligibility is conditioned upon a person’s age and medical diagnosis. For example, the Court points out, children of both sexes with diagnoses such as precocious puberty remain eligible to receive puberty blockers. Therefore, the Court reasoned, because age and diagnosis are not suspect classes subject to heightened scrutiny, the Court is only required to subject the law to rational basis review to determine whether it violates the Equal Protection Clause.

Rational basis review asks only whether the law is rationally, or plausibly, related to a legitimate governmental interest. The majority found that SB1 demonstrates Tennessee’s interests; the bill identifies several purported concerns with the provision of puberty blockers and hormones for the purposes of affirming a minor’s gender when that gender is inconsistent with their sex assigned at birth, including, according to the Tennessee legislature, that minors can become “irreversibly sterile” and face “sometimes fatal psychological consequences,” and that less invasive approaches may result in better outcomes for minors experiencing gender dysphoria. Skrmetti, slip op. at 4, 21. Further, the Court found that SB1’s ban on the provision of puberty blockers and hormones to minors for purposes of treating gender dysphoria is a direct response to the legislature’s concerns about that treatment.

Acknowledging that there may be different ways to draw lines regarding access to certain medical treatments, and citing its 2007 decision in Gonzales v. Carhart, 550 U.S. 124, 163, the majority emphasized that states must be given “wide discretion to pass legislation in areas where there is medical and scientific uncertainty.” Skrmetti, slip op. at 22–23. The majority ended its opinion by noting that the Equal Protection Clause does not resolve disagreements about the provision of gender-affirming care to minors, and that the Court leaves questions about these laws to “the people, their elected representatives, and the democratic process.” Id. at 24.

Dissenting Opinion

In her dissenting opinion, Justice Sotomayor, joined by Justice Jackson and, in part, Justice Kagan, attacked the majority’s characterization of SB1 as discriminating based on age and medical condition, noting,

This case presents an easy question: whether SB1’s ban on certain medications, applicable only if used in a manner ‘inconsistent with . . . sex,’ contains a sex classification. Because sex determines access to the covered medications, it clearly does. Yet the majority refuses to call a spade a spade. Instead, it obfuscates a sex classification that is plain on the face of this statute, all to avoid the mere possibility that a different court could strike down SB1, or categorical health care bans like it.

Skrmetti, slip op. at 31 (Sotomayor, J., dissenting). The dissenting Justices would have applied heightened scrutiny and Justices Sotomayor and Jackson would have found the statute violates the Equal Protection Clause. Justice Kagan did not reach the issue of whether SB1 violated the Equal Protection Clause and would have remanded for further proceedings.

Implications of the Supreme Court’s Decision

The Supreme Court’s decision is likely to have a significant impact on minors’ ability to receive (and medical professionals to provide) gender-affirming care in many states. Some outstanding questions and takeaways from the Supreme Court’s decision are discussed below.

• Is Transgender Status a Suspect Class? The majority did not resolve the question of whether transgender status is a suspect class subject to heightened scrutiny under the Equal Protection framework. Rather, they sidestepped that analysis altogether by viewing the law through the lens of discrimination based on age and medical condition, not sex. In her concurring opinion, Justice Barrett expressly noted that the Court did not resolve this question, and she wrote separately “to explain why, in my view, [transgender status] does not” constitute a suspect class. Skrmetti, slip op. at 1 (Barrett, J., concurring). Thus, the question of scrutiny standards will continue to be litigated. In a way, because the majority declined to go so far as concluding that transgender status is not a suspect class, Skrmetti leaves open the door for additional challenges that may otherwise have been foreclosed with a more explicit position on the standard of review.
• The Medical Evidence Is Complicated. The decision focused heavily on the Justices’ impression that the evidence about gender-affirming care for minors is complex and the subject of significant debate. For example:
  • Justice Roberts, in the closing paragraph, said this case “carries with it the weight of fierce scientific and policy debates about the safety, efficacy, and propriety of medical treatments in an evolving field. The voices in these debates raise sincere concerns; the implications for all are profound.” Skrmetti, slip op. at 24. But the court’s role, Justice Roberts said, is “only to ensure that” the law “does not violate” the Equal Protection Clause. “Having concluded that it does not, we leave questions regarding its policy to the people, their elected representatives, and the democratic process.” Id.
  • In her dissent, Justice Kagan wrote: “The record evidence here is extensive, complex, and disputed, and the Court of Appeals (because it applied only rational-basis review) never addressed the relevant issues.” Skrmetti, slip op. at 1 (Kagan, J., dissenting).
  • In his separate concurring opinion, Justice Thomas chided both sides at times for over-stating the weight of the evidence in their respective favor, noting: “The Court rightly rejects efforts by the United States and the private plaintiffs to accord outsized credit to claims about medical consensus and expertise.” Skrmetti, slip op. at 5 (Thomas, J., concurring). Justice Thomas further stated that the case “carries a simple lesson: In politically contentious debates over matters shrouded in scientific uncertainty, courts should not assume that self-described experts are correct.” Id. at 22.
• The Court Disagrees on the Appropriateness of the Breadth of this Decision. Some felt the majority went too far in actually scrutinizing SB1, arguing that only the question before the Court was which level of scrutiny should be utilized. The dissenting Justices noted that “[a]ll the United States requested of this Court was confirmation that intermediate scrutiny applied.” Skrmetti, slip op. at 30 (Sotomayor, J., dissenting). Both Justices Sotomayor’s and Kagan’s dissents argued that the more appropriate remedy was for the Court to remand this to the lower court with instructions to apply the correct standard of review.
• Justice Thomas Signals Other State Interests in Gender-Affirming Care. In Justice Thomas’s concurrence, he noted that states “must decide for themselves” the issue of whether “children can provide informed consent to irreversible sex-transition treatments.” Skrmetti, slip op. at 5 (Thomas, J., concurring). He went on to characterize these questions as one of medical ethics best left to the states.
• The Opinion Is Narrow in Some Ways. The Court’s holding is narrowly tailored to laws regulating access to gender-affirming care for minors. In that way, it leaves open the possibility that other discrimination challenges brought by transgender individuals may nonetheless be subject to heightened scrutiny.
• The Supreme Court’s Decision Is Likely to Perpetuate Patchwork Access to Gender-Affirming Care Across States. Importantly, Skrmetti does nothing to limit access to gender-affirming care for minors in states that do not presently ban or restrict such care, or where states have taken extra steps to protect this type of health care. However, at present, 27 states have enacted some form of restrictions on gender-affirming care for minors, many of which have been challenged, and those challenges are currently making their way through the court system. To the extent pending federal litigation hinges on whether these laws violate the Equal Protection Clause or states look to federal comparisons to inform interpretations of their own state constitutions, we expect some state governments will argue that the Supreme Court has now resolved this question, though these cases may raise additional arguments that will allow them to survive Skrmetti. Further, several federal court cases regarding states’ gender-affirming care laws have specifically stayed proceedings pending the outcome of Skrmetti¸ irrespective of whether those cases may turn on different grounds. These include Alabama, Georgia, Indiana, South Carolina, and Oklahoma. Even beyond these states, there is likely to be continued litigation on other bases in the coming months and years.

For more information about this decision and other developments relating to gender-affirming care laws throughout the country, please reach out to one of the authors.