The Supreme Court on Wednesday upheld Tennessee’s law banning gender-affirming care for minors in a 6-3 ruling. Legal experts fear the ruling could set a tone for how the courts handle transgender rights and sex discrimination cases for years to come.
Chief Justice John Roberts authored the majority opinion while Justices Elena Kagan, Sonia Sotomayor, and Ketanji Brown Jackson dissented. In the ruling, the court held that the Tennessee ban was “not subject to heightened scrutiny under the Equal Protection Clause,” allowing the ban to remain in place.
This decision focused solely on Tennessee’s ban, foreclosing most medical care options to transgender youth in the state. It also marks the second blow the Supreme Court has dealt to transgender rights advocates recently, after the highest court allowed President Donald Trump’s ban on transgender service members in the military to take effect in May.
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At the heart of United States v. Skrmetti is Tennessee’s Senate Bill 1, which passed in March 2023 and banned gender-affirming care for minors, such as puberty blockers and hormone therapy, as well as surgical care, which is already extremely rare. Less than a month after the bill was signed into law, three families of trans youth and one Memphis-based doctor filed a lawsuit, alleging that SB 1’s provisions on hormones and puberty blockers violated the equal protection clause of the 14th Amendment, which has been interpreted to include discrimination based on sex since the 1970s.
The Supreme Court’s ruling clears the way for officials in Tennessee to deny gender-affirming treatments like puberty blockers and hormone therapy to transgender youth.
The majority opinion, in which Roberts was joined by Justices Clarence Thomas, Samuel Alito, Brett Kavanaugh, Neil Gorsuch and Amy Coney Barrett, concluded that Tennessee’s SB 1 did not discriminate on the “basis of transgender status.”
“Rather, it removes one set of diagnoses — gender dysphoria, gender identity disorder, and gender incongruence — from the range of treatable conditions,” Roberts wrote. Thomas and Barrett also each wrote concurring opinions.
The court ruled that the law was permissible under rational basis review, a more lenient standard of legal review that considers whether government actions are rationally connected to a legitimate state interest. The plaintiffs in the case had argued that because the law dealt with sex-based classifications, it should be looked at under a higher level of review, strict scrutiny, which is applied when a fundamental constitutional right is in question.
The court denied that claim. “The plaintiffs argue that SB1 warrants heightened scrutiny because it relies on sex-based classifications. But neither of the above classifications turns on sex. Rather, SB1 prohibits healthcare providers from administering puberty blockers or hormones to minors for certain medical uses, regardless of a minor’s sex,” Roberts wrote.
Instead, Roberts concluded that questions regarding the regulation of treatments like puberty blockers and hormone therapy for minors should be left “to the people, their elected representatives, and the democratic process.”
Meanwhile, Thomas appeared to cast doubt on gender dysphoria as a legitimate medical concern altogether.
“This case carries a simple lesson,” he wrote. “In politically contentious debates over matters shrouded in scientific uncertainty, courts should not assume that self-described experts are correct.”
“The Court today renders transgender Americans doubly vulnerable to state-sanctioned discrimination.”
– Justice Sonia Sotomayor, in her dissent
In her dissent, Sotomayor wrote that the ban fails to take into account the decisions between families of trans youth and their doctors, nor the severity of a child’s mental health or gender dysphoria.
“The Court today renders transgender Americans doubly vulnerable to state-sanctioned discrimination,” she wrote, arguing that the decision does “irrevocable damage to the Equal Protection Clause and invites legislatures to engage in discrimination by hiding blatant sex classifications in plain sight.”
On a press call Wednesday afternoon, LGBTQ+ legal advocates cautioned that despite the blow to trans youth in Tennessee, the decision was written in a relatively narrow way, which still leaves the door open for lower courts to trigger heightened scrutiny in challenges to other state bans.
She pointed to other legal tools and theories, such as equal protection arguments based on parental rights or transgender status, as well as Title IX and Title VII claims, that can still be leveraged in pending cases.
Unlike in the Sixth Circuit’s decision on Skrmetti, the Supreme Court Wednesday did not even try to wade into the waters of debating whether the rationale in the 2020 landmark Bostock ruling, which held that transgender workers are entitled to equal protection on the basis of gender identity and sexual orientation, applied to the ban. This could be considered a small victory, as at least one Texas judge, Matthew Kacsmaryk, has worked to minimize its impact at the federal level.
“The decision is hard to stomach,” Karen Loewy, the director of the constitutional law practice at Lambda Legal, said. “But it’s important to note that there’s nothing in this decision that is a green light.”
Over the past five years, these treatments have been targeted by a deluge of anti-trans legislation, despite a robust body of research and many major American medical associations supporting gender-affirming care to alleviate gender dysphoria, anxiety and depression among trans youth. So far, 24 states have passed bans on gender-affirming care for minors across the country, and several carry a felony provision for clinicians who provide care to minors. By contrast, only 17 states and Washington, D.C., have passed “shield” laws that protect access to transgender health care.
In practice, this has meant more than 30% of trans youth live in a state that has some type of ban on access to care. Trans youth who live in restrictive states and their families have often had to spend hundreds, if not thousands, of dollars to travel out of state to reach gender-affirming care providers. This month, HuffPost spoke with Diane, the mother of a 13-year-old transgender girl in Nashville. After the state banned care, Diane said her family drove to Ohio three times to establish care at a pediatric gender clinic. When Ohio passed its own ban in January 2024, the family had to find another clinic further away in Washington, D.C.
“The idea that I’m letting my daughter follow some whim is insulting,” Diane told HuffPost. “This is not a whim, this is not a phase — this is who she is.”
Families in Tennessee and Texas have also had to grapple with hostile Republican-controlled state governments trying to obtain sensitive patient medical data and threats from attorneys general categorizing the act of providing transition care as child abuse.
More often than not, though, most transgender youth are not receiving any kind of gender-affirming care. A 2025 study in JAMA Pediatrics found that only 0.1% of transgender teens with private insurance received puberty blockers or hormone treatments. The use of these treatments is broadly supported by decades of scientific research and by a swath of American medical groups, including the American Academy of Pediatrics.
New Orleans teen Kyle said that being able to take testosterone allowed him to fit in with his peers. “I describe it as getting caught up with other boys my age,” he said, and noted that he’s enjoyed hearing his voice deepen.
But since Trump returned to office in January, his administration has pushed forward a slew of executive orders, policy changes and recommendations to curb the availability of this care for both minors and adults who rely on federal assistance programs. Health and Human Services Secretary Robert F. Kennedy Jr. also released a 409-page review promoting “psychotherapy” instead of hormone therapy and puberty blockers.
The ruling in Skrmetti was not entirely unexpected: During oral arguments in December, the conservative justices seemed poised to side with Tennessee.
In its court briefing, Tennessee had argued that SB 1 does not specifically target trans people but instead bars medication for minors based on their age and when the medication was used for the “purpose of gender transition.” The text of the law explicitly states that Tennessee’s interest in enforcing this law is to encourage “minors to appreciate their sex” and to not “become disdainful of their sex.”
Under President Joe Biden, the Justice Department stood in firm opposition to Tennessee’s law regulating access to trans health care, joining the lawsuit on the side of the plaintiffs. Both Elizabeth Prelogar, the United States solicitor general under Biden, and Chase Strangio, the director of the American Civil Liberties Union’s LGBT & HIV Project, which represented the families and doctor, argued that the law creates a clear “sex-classification” distinction as it denies medical care to trans minor patients only when treatments “induced physical effects inconsistent with birth sex.” In other words, cisgender children would still be able to take the same hormone or puberty blocker treatments, which are prescribed for conditions such as precocious puberty, so long as they are not doing so to treat gender dysphoria.
In February, however, the Trump administration reversed the Justice Department’s position in Skrmetti, in a move that was largely anticipated as Trump spent much of his time on the campaign promising to outlaw gender-affirming care.
“The government’s previously stated views no longer represent the United States’ position,” Curtis Gannon, the deputy solicitor general under Trump wrote in a letter to the Supreme Court. However, he cautioned the court against dismissing the case altogether and wrote that the court’s “prompt resolution of the question” will impact a cache of other cases pending in the lower courts.
Currently, there are 15 pending cases involving challenges to gender-affirming care bans at the state level. So far, Arkansas has been the only state to receive a permanent injunction on its ban from a federal judge in 2023. Arkansas Attorney General Tim Griffin has appealed the ruling.
“Today’s ruling is a devastating loss for transgender people, our families, and everyone who cares about the Constitution,” Strangio said in a statement after the ruling was announced.
“Though this is a painful setback, it does not mean that transgender people and our allies are left with no options to defend our freedom, our health care, or our lives,” he continued. “We are as determined as ever to fight for the dignity and equality of every transgender person and we will continue to do so with defiant strength, a restless resolve, and a lasting commitment to our families, our communities, and the freedom we all deserve.”
