Supreme Court Upholds Tennessee’s Ban on Gender-Affirming Care for Minors

The Supreme Court of the United States delivered a significant ruling on June 8, 2025, in the case of United States v. Skrmetti, affirming the Sixth Circuit’s decision. This ruling effectively upholds Tennessee’s Senate Bill 1 (SB1), a state law that prohibits certain medical procedures for transgender minors. This pivotal announcement establishes the immediate enforceability of SB1 within Tennessee, removing the prior injunction that had temporarily halted its implementation. The progression of this case through the District Court, Sixth Circuit, and finally to the Supreme Court signifies a definitive legal resolution for Tennessee, clarifying the legal landscape for care for transgender minors within its borders.

Beyond its immediate impact in Tennessee, this decision carries substantial weight for states across the nation. Over 20 states have already enacted similar prohibitions on gender-affirming care for minors. By upholding Tennessee’s law, particularly under the highly deferential rational basis review, the Supreme Court has provided a robust legal framework that could strengthen and accelerate legislative efforts in other states. This outcome may make it more challenging for plaintiffs to successfully challenge comparable laws in federal courts, potentially influencing the trajectory of legislative trends nationwide.

The Case at a Glance: United States v. Skrmetti

Tennessee’s Senate Bill , enacted in March 2023, specifically targets medical interventions related to gender identity for minors. SB1 explicitly prohibits healthcare providers from prescribing, administering, or dispensing puberty blockers or hormones to any minor for the purpose of enabling them to identify with an identity inconsistent with their biological sex, or to treat discomfort stemming from a discordance between their biological sex and asserted identity. Crucially, the law explicitly excludes gender dysphoria, gender identity disorder, and gender incongruence from the list of treatable conditions for minors. However, it permits the administration of puberty blockers and hormones for other medical purposes, such as treating congenital defects, precocious puberty, disease, or physical injury.

The legal challenge to SB1 began when three transgender minors, their parents, and a doctor filed a pre-enforcement suit, asserting that the law violated the Equal Protection Clause of the Fourteenth Amendment. The United States government intervened in support of the plaintiffs. The District Court initially granted a partial injunction against SB’s enforcement. It concluded that transgender individuals likely constitute a quasi-suspect class, that SB1 discriminated on the basis of sex and transgender status, and that the law was unlikely to survive intermediate scrutiny.

However, the Sixth Circuit Court of Appeals reversed this decision. The Sixth Circuit determined that SB1 did not trigger heightened scrutiny, finding that the law did not classify on the basis of sex or transgender status. Instead, it concluded that SB1 satisfied rational basis review. This fundamental disagreement over the appropriate standard of judicial review—whether heightened (intermediate) scrutiny or the more lenient rational basis review should apply—became the central legal battleground throughout the case, ultimately dictating the outcome at each court level.

The specific language and framing of SB1 by the Tennessee legislature proved instrumental in the Supreme Court’s decision to apply rational basis review. By structuring its prohibitions around “age” and “medical use” classifications, rather than explicitly targeting “sex” or “transgender status,” the law’s drafting allowed the Court to bypass arguments for heightened scrutiny. The majority opinion explicitly stated that SB1 “does not mask sex-based classifications,” indicating that the precise way a law is formulated, even if its practical effects are discriminatory, can significantly influence the level of judicial examination it receives.

The Supreme Court’s Decision: Rational Basis Review Applied

The Supreme Court’s core holding in United States v. Skrmetti is that Tennessee’s SB1 is not subject to heightened scrutiny under the Equal Protection Clause and successfully passes rational basis review. This signifies a highly deferential approach to the legislative judgment.

The Court’s majority reasoned that SB1 classifies based on age (allowing certain treatments for adults but not minors) and medical use (permitting puberty blockers and hormones for minors to treat certain conditions but not gender dysphoria, gender identity disorder, or gender incongruence). It explicitly rejected the argument that a “mere reference to sex” or the law’s application based on sex was sufficient to trigger heightened scrutiny, particularly within the medical context where some treatments are inherently linked to biological sex. The Court clarified that SB1 prohibits specific medical treatments (puberty blockers and hormones for gender dysphoria, identity disorder, or incongruence) for all minors, regardless of their biological sex.

Furthermore, the Court declined to rule on whether “transgender status” constitutes a suspect or quasi-suspect class for Equal Protection purposes. It reasoned that SB1 simply removes a specific set of diagnoses—gender dysphoria, gender identity disorder, and gender incongruence—from the range of treatable conditions, rather than classifying based on transgender status itself. This approach drew parallels to the precedent set in

Geduldig v. Aiello (974), where the Court held that excluding pregnancy-related disabilities from coverage was not sex discrimination, despite pregnancy being unique to biological women.

Crucially, the Supreme Court chose not to extend the reasoning of Bostock v. Clayton County (2020) beyond the Title VII employment context to the Equal Protection Clause.

Bostock held that discrimination based on gay or transgender status is a form of sex discrimination under Title VII’s employment protections. The Court in Skrmetti argued that applying Bostock‘s “but-for causation” test would not alter SB’s application. For instance, if a transgender boy (assigned female at birth) sought testosterone for gender dysphoria, SB1 would prevent it. Even if his biological sex were changed to male, SB1 would still not permit the hormones because he would lack a “qualifying diagnosis” (such as a congenital defect). This interpretation suggests that neither sex nor transgender status was the but-for cause of the inability to obtain treatment under SB.

Tennessee’s justifications for SB, which the Court found to be rationally related to the state’s objective of protecting minors’ health and welfare, included concerns about:

• Irreversible sterility.
• Increased risk of disease and illness.
• Adverse psychological consequences.
• Minors’ perceived lack of maturity to fully understand these consequences.
• The potential for regret among individuals who underwent such treatments as minors.
• The experimental nature of these treatments and the unknown full effects.

The Court bolstered its acceptance of these justifications by citing international reports, such as the Cass Review in England, which characterized the evidence for using puberty blockers and hormones to treat transgender minors as “remarkably weak”. Such reports, the Court stated, “underscore the need for legislative flexibility” in areas of “medical and scientific uncertainty”. The Court emphasized that its role is not “to judge the wisdom, fairness, or logic” of SB, but only to ensure it does not violate equal protection guarantees, thus leaving policy questions to the democratic process.

This decision reflects a judicial philosophy of deep deference to state legislatures in complex, evolving scientific and medical fields, particularly when minors are involved. The Court’s strong emphasis on “wide discretion to pass legislation” and its assertion that policy questions are “appropriately left to the people, their elected representatives, and the democratic process”  underscores a prioritization of legislative authority over potential individual rights claims in such contexts.

The Court’s detailed explanation of why SB’s classifications—based on age and specific medical diagnoses—do not trigger heightened scrutiny effectively provides a legal blueprint for other states. Legislatures can now refer to this opinion to craft similar laws that aim to restrict gender-affirming care while attempting to avoid more rigorous judicial review. By framing prohibitions around specific “diagnoses” or “medical uses” rather than explicitly targeting “transgender individuals” or “sex,” states may successfully bypass heightened scrutiny.

It is important to acknowledge the significant disagreement within the Court. Dissenting justices, Sotomayor and Kagan, strongly contended that the majority’s characterization of SB1 as sex-neutral “contorts logic and precedent”. They argued that the law plainly discriminates on the basis of sex and transgender status, necessitating intermediate scrutiny, highlighting the deep divisions within the Court on this contentious issue.

Implications for Transgender Children’s Healthcare

The Skrmetti ruling has immediate and profound consequences for transgender minors in Tennessee. The state’s ban on puberty blockers and hormones for gender dysphoria is now fully enforceable. This may compel families seeking such care to pursue options outside the state, creating significant logistical, emotional, and financial burdens.

For other states, this decision sets a broad legal precedent, making it considerably easier to enact and defend similar bans on gender-affirming care for minors. By applying the highly deferential rational basis review, states are now better positioned to withstand legal challenges to such legislation. This creates a notable tension between state law and the prevailing consensus of major medical organizations, such as the American Academy of Pediatrics and the American Medical Association, which widely support gender-affirming care as medically necessary. The Court’s deference to legislative findings, even when they appear to contradict established medical consensus, could lead to a broader trend where state legislatures, rather than medical professionals, increasingly dictate standards of care for specific conditions, particularly those deemed “controversial” or “uncertain.” This judicial skepticism towards established medical consensus, combined with the low bar of rational basis review, empowers states to legislate against widely accepted professional guidelines, potentially leading to a fragmentation of healthcare standards across the nation and undermining the autonomy and authority of medical professionals in providing care based on their expertise.

This ruling will likely spur continued legal challenges against similar laws in other states, though plaintiffs will now face a higher burden to demonstrate constitutional violations. The practical consequence for families of transgender minors facing such bans is often the necessity of seeking care elsewhere, leading to interstate travel or even relocation. This creates new social and legal pressure points, impacting families’ fundamental choices about residence and access to necessary healthcare.

What This Means for Transgender Adults

It is important to note that Tennessee’s SB1 explicitly limits its prohibitions to minors, defined as individuals under 8 years of age. Therefore, transgender adults in Tennessee are not directly affected by this specific law’s bans on medical care.

However, the Supreme Court’s reasoning in Skrmetti sends implicit signals that could have future ramifications for transgender adults. A key aspect of the decision was the Court’s explicit choice to decline to address whether the reasoning of Bostock v. Clayton County—which established that discrimination based on gay or transgender status constitutes sex discrimination under Title VII—extends beyond the employment context to the Equal Protection Clause. By not extending Bostock to trigger heightened scrutiny for laws affecting transgender status, the Court indicates a reluctance to apply a higher standard of review to laws impacting transgender individuals generally, including adults, if those laws are not explicitly based on traditional biological sex. This suggests that future challenges to laws affecting transgender adults, if not framed as traditional sex discrimination, might also be subject to rational basis review.

Furthermore, the Court’s argument that SB1 classifies based on “medical use” (specifically, diagnoses like gender dysphoria) rather than “transgender status” could be extended to adult contexts. If states choose to regulate adult gender-affirming care, they might attempt to draft laws that mimic SB’s “medical use” or “diagnosis-based” framing. This approach could allow them to regulate adult care by focusing on the medical condition rather than the individual’s identity, potentially benefiting from the highly deferential rational basis review.

The Skrmetti decision introduces a layer of uncertainty into the broader legal landscape for LGBTQ+ rights. While Bostock marked a significant victory for employment rights, Skrmetti suggests a more limited application of its reasoning in other constitutional contexts. This may signal a judicial reluctance to expand LGBTQ+ protections beyond specific statutory interpretations, creating broader uncertainty for the community regarding future Equal Protection challenges.