United States v. Skrmetti
Whether Tennessee's SB1, which bans gender-affirming medical treatments (puberty blockers and hormones) for minors when used inconsistently with their birth sex, constitutes a sex-based classification that triggers heightened scrutiny under the Equal Protection Clause of the Fourteenth Amendment.
Background & Facts
Tennessee enacted SB1, a law that prohibits medical providers from prescribing puberty blockers and hormones to minors when used to allow a minor to 'identify with or live as a gender inconsistent with the minor's sex.' The same medications remain freely available for other medical purposes, including treating precocious puberty and other conditions. The law does not ban these treatments for adults.
Several families with transgender adolescents, along with the United States government, challenged SB1 as unconstitutional sex discrimination under the Equal Protection Clause. The plaintiffs included adolescents like 'Ryan Roe,' who described severe gender dysphoria that caused him to vomit before school daily and consider going mute because his voice caused such distress, and 'John Doe,' who had been receiving puberty blockers to allow a typical male puberty before the law cut off access.
The district court conducted a trial and made extensive factual findings, concluding that many of the risks Tennessee cited were not unique to gender-affirming care and that the state left similar risks unregulated in other pediatric contexts. The district court also found that rates of regret among those who receive these treatments after the onset of puberty are as low as 1 percent, far lower than regret rates for treatments SB1 expressly permits.
The Sixth Circuit Court of Appeals reversed, holding that SB1 does not classify on the basis of sex and should be reviewed under rational basis — the most lenient standard of judicial review. The United States then asked the Supreme Court to review whether the Sixth Circuit applied the wrong legal standard.
The case arises against a backdrop of significant international debate. European countries including the United Kingdom, Sweden, Finland, and Norway have tightened guidelines around these treatments for minors, though none has imposed a categorical ban like Tennessee's. The UK's Cass Report, released in 2024, called for more individualized assessment but acknowledged these treatments can be medically indicated for some adolescents.
Why This Case Matters
This case represents the first time the Supreme Court has considered the constitutionality of laws restricting gender-affirming medical care for transgender minors, an issue implicated by laws in over 20 states. The Court's decision on the threshold question — whether such laws involve sex-based classifications requiring heightened judicial scrutiny — will have sweeping implications not only for medical care access but potentially for how courts evaluate any law that draws distinctions related to sex or transgender status.
Beyond the immediate medical context, the Justices explored how a ruling here could affect other contested areas, particularly laws governing women's and girls' sports participation by transgender athletes and access to sex-separated spaces like bathrooms. The case also raises fundamental questions about the judiciary's role in reviewing laws touching on evolving medical science, the boundaries of legislative authority versus constitutional protections, and whether transgender status should be recognized as a suspect or quasi-suspect classification entitled to heightened protection in its own right.
The Arguments
SB1 is a facial sex-based classification because it restricts access to medications based on whether the treatment is 'inconsistent with' a patient's birth sex — meaning if you change the individual's sex, the legal result changes. This triggers heightened scrutiny under decades of equal protection precedent, and Tennessee has not justified this sex-based line.
- SB1 on its face says you cannot have medications inconsistent with your sex, which is the same structure as saying you cannot dress or pursue a profession inconsistent with your sex — classifications Tennessee concedes are sex-based
- The law is both severely overinclusive (banning care even when medically necessary for individual patients) and severely underinclusive (leaving the same medications entirely unregulated for other purposes with comparable risks)
- No European country that has tightened guidelines has imposed a categorical ban; the UK's Cass Report and all cited jurisdictions acknowledge this care can be medically necessary for some adolescents
- West Virginia's more tailored law — requiring two diagnoses, mental health screening, parental consent, and a finding of medical necessity — demonstrates that less restrictive alternatives exist
- The law overrides the judgment of parents, patients, and doctors in a sharp departure from how Tennessee normally handles pediatric medical decision-making
Key Exchanges with Justices
Chief Justice Roberts
“Unlike cases like Craig v. Boren involving simple stereotyping about men and women, doesn't the heavy medical complexity here make a stronger case for leaving these determinations to legislatures rather than courts?”
Revealed Roberts's concern that the Court lacks expertise to resolve disputed medical questions and may prefer to defer to legislatures in this arena, though he later confirmed legislation is still subject to judicial review.
Justice Alito
“Would you like to stand by your petition's claim of 'overwhelming evidence' that these treatments improve well-being, given that Swedish and UK health authorities have since found that risks likely outweigh benefits?”
Showed Alito's deep skepticism about the medical justification for these treatments and suggested he views the evolving European landscape as undermining the petitioner's case.
Justice Kavanaugh
“If there are strong scientific and policy arguments on both sides, and the Constitution doesn't take sides, why isn't it best to leave this to the democratic process? And if you prevail on the standard of review, what would that mean for women's and girls' sports?”
Revealed Kavanaugh as a potential swing vote who is sympathetic to the argument that legislatures should decide but also open to the sex-classification argument; his sports question showed concern about unintended consequences of a broad ruling.
Justice Kagan
“Why should we think of this primarily as a sex-based classification rather than discrimination based on transgender status, since both trans males and trans females are on one side of the line and both cis males and cis females are on the other?”
Suggested Kagan sees the transgender status classification as the real driver but wanted to understand how sex-based and transgender-status-based analyses interact and reinforce each other.
Justice Jackson
“Isn't there a parallel to Loving v. Virginia, where anti-miscegenation laws applied equally to both races but the Court still found a racial classification? Could Virginia have avoided scrutiny by just reframing its law as prohibiting 'inconsistent' marriages?”
Revealed Jackson's strong view that the law is making a sex-based classification and that arguments about 'equal burden on both sexes' were rejected in the race context and should be rejected here.
Justice Barrett
“Is there a history of de jure discrimination against transgender people comparable to that experienced by women or racial minorities, which we've relied on when recognizing suspect classes?”
Showed Barrett taking the transgender-status classification question seriously but expressing hesitation about recognizing a new suspect class without the traditional markers, while remaining open to the sex-classification path.
SB1 bans medical care only when it is inconsistent with a person's birth sex, creating a facial sex classification that warrants heightened scrutiny. The law took away the only treatment that relieved years of suffering for the adolescent plaintiffs, and Tennessee's arguments that SB1 is sex-neutral would apply equally if the state banned this care for adults.
- A birth male can receive treatment to live and identify as a boy but a birth female cannot — the only variable is sex
- The often-cited 85 percent desistance rate refers to older studies of prepubertal children, while the medications at issue are only prescribed after puberty onset; after puberty onset, regret rates are approximately 1 percent
- Courts are equipped to assess whether laws are properly tailored, as they do in other contexts involving public health and evolving science, including the COVID-19 cases
- There is a history of de jure discrimination against transgender people including criminal bans on cross-dressing and explicit bans on military service
- Transgender people are a discrete minority facing a wave of legislation and have difficulty protecting themselves through the political process
Key Exchanges with Justices
Justice Thomas
“If you are successful, what would your remedy be in practical terms?”
Revealed Thomas's skepticism about the equal protection framing, as he tried to identify which group gets what benefit compared to which other group, echoing the structure of traditional equal protection cases.
Justice Alito
“Is transgender status immutable? Are there not people who identify as one gender at one time and another gender later?”
Showed Alito's skepticism about recognizing transgender status as a quasi-suspect class and his concern about distinguishing it from disability classifications the Court has declined to give heightened protection.
Justice Kavanaugh
“Either way you go, some people will be harmed — those denied treatment or those who receive it and later regret it. Why isn't choosing between those groups a question for policymakers rather than courts?”
Highlighted Kavanaugh's central concern about institutional competence and his view that this may be a case where reasonable people can disagree on policy, making it difficult for courts to choose sides.
SB1 draws lines based on medical purpose, not sex. Using puberty blockers to treat precocious puberty is a fundamentally different medical treatment from using them to facilitate gender transition, and the Equal Protection Clause does not require states to treat unlike medical treatments the same.
- Both boys and girls are equally prohibited from receiving these medications for the purpose of transitioning; the restriction turns entirely on medical purpose
- Giving testosterone to a boy with a deficiency allows normal development, while giving it to a girl causes a medical condition (hyperandrogenism) with distinct risks including infertility, blood cell disorders, and increased heart attack risk
- Half the states, plus Sweden, Finland, and the UK, now restrict these interventions for minors, recognizing the uncertainty surrounding their use
- European systematic reviews have found no established benefits from these treatments, and they carry often irreversible, life-altering consequences
- Politically accountable lawmakers, not judges, are best positioned to assess this evolving medical question, and the Constitution leaves this policy choice to the democratic process
Key Exchanges with Justices
Justice Jackson
“If a biologically male child can get medication to deepen his voice to affirm his masculinity but a biologically female child cannot get that same medication for the same purpose, isn't that differentiating on the basis of sex?”
Forced Tennessee's counsel to eventually concede that under SB1 specifically, the boy could get the medication but the girl could not, undermining the argument that the law classifies only by purpose and not by sex.
Justice Kagan
“The law's stated purpose includes encouraging minors to 'appreciate their sex' and preventing them from becoming 'disdainful of their sex' — doesn't that show the law is fundamentally about enforcing gender conformity rather than protecting health?”
Put Tennessee on the defensive about the law's purpose and suggested Kagan views the stereotyping rationale as a significant problem for the state's defense of the law.
Justice Sotomayor
“You're saying your state could block gender treatment for adults too under rational basis review? When you're 1 percent of the population, how is the democratic process going to protect you?”
Highlighted Sotomayor's concern that rational basis review is wholly insufficient to protect a small, politically vulnerable minority and that Tennessee's position has no limiting principle.
Justice Barrett
“You say boys and girls are not similarly situated at step one, but isn't recognizing their lack of similarity itself a sex-based classification?”
Revealed a potential flaw in Tennessee's core argument and suggested Barrett may be inclined toward finding a sex-based classification while remaining uncertain about the appropriate level of scrutiny.
Precedent Cases Cited
Bostock v. Clayton County
590 U.S. 644
Both sides debated whether the reasoning from this Title VII case — that discriminating based on transgender status inherently involves sex — should apply in the equal protection context.
Geduldig v. Aiello
417 U.S. 484
Tennessee argued this case shows that laws affecting a medical condition associated with one sex are not automatically sex classifications.
Dobbs v. Jackson Women's Health Organization
597 U.S. 215
Justice Alito cited Dobbs as reaffirming Geduldig's principle that laws affecting a sex-specific medical condition are not necessarily sex classifications.
Craig v. Boren
429 U.S. 190
Referenced as a classic sex discrimination case that established intermediate scrutiny, but one that the Chief Justice suggested involved simpler issues than the medical complexities here.
Loving v. Virginia
388 U.S. 1
Justice Jackson drew a structural parallel between anti-miscegenation laws and SB1, arguing both prohibit conduct 'inconsistent with' a protected characteristic.
City of Cleburne v. Cleburne Living Center
473 U.S. 432
Discussed in the context of whether the Court should recognize new quasi-suspect classes and whether rational basis review can still invalidate laws rooted in prejudice.
Village of Arlington Heights v. Metropolitan Housing Development Corp.
429 U.S. 252
Discussed as the framework for analyzing laws that are facially neutral but may have been enacted with discriminatory intent.
Sessions v. Morales-Santana
582 U.S. 47
Referenced as a sex discrimination precedent involving different treatment of mothers and fathers in citizenship law.
Johnson v. California
543 U.S. 499
Cited as an example of the Court sending a case back to lower courts after correcting the standard of review, with guidance on how to apply heightened scrutiny in a specific institutional context.
South Bay United Pentecostal Church v. Newsom
592 U.S. 61
Cited to show the Court has applied heightened scrutiny even when governments are grappling with evolving medical and scientific evidence in public health contexts.