In United States v. Skrmetti, the U.S. Supreme Court found that a Tennessee law prohibiting certain medical treatments for transgender minors did not violate the Equal Protection Clause of the Fourteenth Amendment. The Court’s ruling marks a significant development in the ongoing legal and political battles over transgender rights and state healthcare regulation. The Court explained that Bostock v. Clayton County, 590 U.S. 644 (2020), which held that terminating an employee for being gay or transgender violates Title VII’s prohibition on discharging an individual “because of” their sex, does not alter the Court’s analysis.
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Tennessee’s law, Prohibition on Medical Procedures Performed on Minors Related to Sexual Identity, Senate Bill 1 (“SB1”), prohibits (with limited exceptions) healthcare providers from prescribing, administering, or dispensing puberty blockers or hormones and performing gender-affirming surgeries for individuals under 18 for the purpose of gender transition or treating gender dysphoria.
A group of families and medical providers challenged the law, arguing that it employs classifications that prompt heightened scrutiny and violates the Equal Protection Clause. The Middle District of Tennessee partially enjoined SB1, ruling that the law discriminates on the basis of sex and transgender status, that transgender individuals constitute a quasi-suspect class, and that SB1 was unlikely to survive intermediate scrutiny. On appeal, the Sixth Circuit reversed, holding that SB1 does not include a sex-based classification, that transgender individuals are not a suspect class, and that SB1 would survive rational basis scrutiny.
On June 18, 2025, the Supreme Court affirmed the Sixth Circuit, holding that SB1 does not impose an unconstitutional sex-based or transgender-based classification under the Equal Protection Clause because the law’s classification turns on age (allowing certain medical treatments for adults and not minors) and the purpose behind the medical treatment (permitting puberty blockers or hormones for minors to treat certain conditions but not others). In a majority opinion written by Chief Justice John Roberts, the Court explained that classifications based on age or medical use do not trigger heightened scrutiny. Then, applying rational basis review—the least stringent form of constitutional analysis—the Court concluded that “SB1’s age- and diagnosis-based classifications are plainly rationally related to [the State’s] findings [regarding the potential risks of prescribing puberty blockers or hormones to minors] and the State’s objective of protecting minors’ health and welfare.” Thus, SB1 survived rational basis review.
The Court also declined to address whether the Court’s reasoning in Bostock, which held that federal sex discrimination protections apply to gender identity and sexual orientation in employment settings, extended beyond the Title VII context.
The dissenting opinion, written by Justice Sonia Sotomayor, argued that the law does classify on the basis of sex, as the availability of a treatment depends upon a patient’s sex. By conditioning the availability of medical treatment on a patient’s sex, the law expressly classifies on the basis of sex—effectively discriminating against transgender minors—and therefore should have been subject to heightened scrutiny. The dissent further argued that the law should have been analyzed with heightened scrutiny because Bostock decided that discrimination on the basis of transgender status is a form of sex discrimination triggering such scrutiny.
The Supreme Court’s decision is expected to influence legal battles in other states that have passed or are considering similar legislation. This decision also comes in the wake of President Trump’s January 20, 2025 Executive Order requiring federal agencies to “enforce laws governing sex-based rights, protections, opportunities, and accommodations to protect men and women as biologically distinct sexes,” which we previously discussed here.