Caseflicks

Supreme Court of the United States • 2025

United States v. Skrmetti

605 U.S. 495 | 222 L. Ed. 2d 136 | 145 S. Ct. 1816

Full access

Unlock the video and quiz

The written brief is free to read below. Subscribe to watch the video explainer and take the quiz.

Create an account Log in

Takeaway

In short, the Court held that Tennessee's ban is an age- and diagnosis-based medical regulation, not sex or transgender-status discrimination, and therefore upheld it under highly deferential rational-basis review.

Background

Tennessee enacted Senate Bill 1 (SB1), which bars healthcare providers from prescribing puberty blockers or hormones to minors when the purpose is to enable a minor to identify with or live as an identity inconsistent with the minor’s sex, or to treat distress arising from gender incongruence. The law permits the same medications for minors when used to treat conditions such as congenital defects, precocious puberty, disease, or physical injury, and it does not restrict treatment for adults.

Three transgender minors, their parents, and a doctor brought a pre-enforcement Equal Protection challenge. The United States intervened. The District Court preliminarily enjoined SB1’s medication restrictions, concluding that the law classified on the basis of sex and transgender status, that transgender people were a quasi-suspect class, and that Tennessee was unlikely to satisfy intermediate scrutiny. The Sixth Circuit stayed the injunction and reversed, holding that SB1 was subject to rational-basis review and survived it. The Supreme Court affirmed the Sixth Circuit.

Issues

Issue #1

Whether SB1 classifies on the basis of sex and therefore triggers heightened Equal Protection scrutiny.

Holding

No. SB1 classifies by age and medical use, not by sex, so its medication restrictions do not trigger heightened scrutiny.

Reasoning

The Court identified two facial classifications in SB1. The law distinguishes between adults and minors, and it distinguishes between medical uses: puberty blockers and hormones may be used to treat specified conditions but not gender dysphoria, gender identity disorder, or gender incongruence. Age and medical-use classifications ordinarily receive rational-basis review.

SB1's references to a patient's sex do not themselves make the statute sex based. The Court stressed that medical regulation frequently must use sex-specific terms because some conditions, treatments, and procedures are biologically sex-linked. A mere reference to sex is therefore not the same as a rule prescribing one legal standard for males and another for females.

The Court rejected the plaintiffs' framing of the relevant treatment as simply a drug, such as testosterone or puberty blockers. In the Court's view, a medical treatment includes both the medication and the indication for which it is administered. Thus, puberty blockers for gender dysphoria and puberty blockers for precocious puberty are different medical treatments, even if they involve the same drug.

Under that understanding, SB1 applies alike to minors of either sex: no minor may receive the covered medications to treat gender dysphoria or related diagnoses, while minors of either sex may receive them for permitted diagnoses. The law therefore does not prohibit conduct by one sex that it permits for the other.

The Court also declined to treat Tennessee's stated interest in encouraging minors to appreciate their sex as proof of impermissible sex stereotyping. Because the statute neither overtly nor covertly classifies by sex, heightened scrutiny would require an argument that the law was enacted with invidious discriminatory purpose. The plaintiffs did not press such a claim, and the Court read the findings as expressing Tennessee's stated concerns about the risks and uncertainty of the treatments.

Issue #2

Whether SB1 classifies on the basis of transgender status, or required the Court to recognize transgender persons as a suspect or quasi-suspect class.

Holding

No. SB1 does not classify on the basis of transgender status, so the Court did not decide whether transgender persons constitute a suspect or quasi-suspect class.

Reasoning

Drawing on Geduldig v. Aiello, the Court treated SB1 as excluding particular diagnoses from a range of covered medical uses rather than excluding people because they are transgender. The relevant groups are minors seeking the medications for gender dysphoria, gender identity disorder, or gender incongruence, and minors seeking them for other conditions.

Although only transgender individuals seek treatment for the excluded diagnoses, the Court found no complete identity between transgender status and those diagnoses. The group eligible for treatment under other diagnoses includes both transgender and nontransgender minors. In the Court's view, this resembles Geduldig's distinction between pregnancy-related disabilities and other disabilities, even though only women can become pregnant.

Absent an argument that the diagnosis-based distinction was a pretext for invidious discrimination against transgender people, the Court held that SB1 did not classify by transgender status. It consequently found no need to resolve whether transgender status itself warrants heightened scrutiny.

Issue #3

Whether Bostock v. Clayton County requires SB1 to be treated as sex discrimination under the Equal Protection Clause.

Holding

No. The Court did not decide whether Bostock extends beyond Title VII, but held that SB1 would not be sex based even under Bostock's but-for framework.

Reasoning

Bostock interpreted Title VII's prohibition on employment discrimination 'because of' sex through ordinary but-for causation. The Court reserved the broader question whether that statutory reasoning governs Equal Protection analysis, because it concluded that the plaintiffs' counterfactual did not establish but-for causation here.

A transgender boy seeking testosterone for gender dysphoria remains barred under SB1 if his biological sex is changed in the hypothetical, because the disqualifying feature is still the diagnosis and treatment purpose. Conversely, a minor with a permitted diagnosis may receive the medication regardless of sex or transgender status.

The Court distinguished Bostock's example of an employer penalizing a male employee for attraction to men while tolerating that trait in a female employee. There, changing the employee's sex automatically changes the comparison. Under SB1, changing a patient's sex does not automatically change the medical diagnosis, so sex is not a but-for cause of the denial of treatment.

Issue #4

Whether SB1 survives rational-basis review.

Holding

Yes. SB1 is rationally related to Tennessee's legitimate interest in protecting minors' health and welfare.

Reasoning

Rational-basis review asks only whether any reasonably conceivable facts could rationally support the legislative classification. It gives legislatures substantial latitude, particularly when they regulate medical and scientific questions marked by uncertainty.

Tennessee found that using puberty blockers and hormones to treat gender dysphoria in minors may cause sterility, disease, psychological harms, and other irreversible consequences. The legislature also found that minors may lack the maturity to understand those consequences, that some people later regret treatment, that long-term effects remain uncertain, and that less invasive approaches may be available.

The Court held that the age and diagnosis lines in SB1 rationally respond to those findings. It declined to second-guess Tennessee's decision to allow the medications for some pediatric conditions while prohibiting them for gender dysphoria, emphasizing that imperfect line-drawing does not violate equal protection.

Developments abroad, including the Cass Review and subsequent National Health Service restrictions in England, did not control the meaning of the Constitution. But the Court cited them as evidence that medical authorities continue to debate key factual questions, reinforcing the case for legislative flexibility rather than judicial resolution of the policy dispute.

Concurrences

Justice Thomas

Reasoning

Justice Thomas joined the Court's opinion in full but maintained that Bostock should play no role in Equal Protection analysis. Bostock interpreted Title VII's particular statutory language, especially its use of 'because of' sex; the Equal Protection Clause uses different text and has developed through different doctrine. Importing Bostock's framework, he warned, would unsettle many sex-linked medical regulations and other constitutional classifications.

He also argued that courts should not defer to an asserted medical consensus about treatment for pediatric gender dysphoria. In his view, the evidence concerning puberty blockers, cross-sex hormones, and surgery is contested and evolving, while States may reasonably question whether minors can give informed consent to interventions carrying potentially irreversible effects.

Justice Thomas further questioned the reliability and neutrality of influential professional guidance, especially WPATH's standards. He pointed to what he viewed as weak evidence, political advocacy, and external pressure affecting the standards. These concerns, he concluded, reinforce judicial restraint and leave Tennessee free to make its own policy judgment.

Justice Barrett

Reasoning

Justice Barrett agreed that SB1 does not classify by transgender status, but wrote to explain why transgender status would not qualify as a suspect or quasi-suspect classification in any event. In her view, the Court's suspect-class doctrine is narrow and has recognized no new class for decades.

She reasoned that transgender status is not marked by the same obvious, immutable, and readily ascertainable characteristics associated with race or sex. Gender identity may emerge at different ages, may change over time, and encompasses a broad and diverse set of identities rather than a discrete group with fixed boundaries.

Justice Barrett also emphasized that recognizing transgender status as a suspect class would place courts in the position of closely reviewing legislative decisions across health care, school sports, restroom access, and related fields. In areas involving medical and policy uncertainty, she concluded, rational-basis review preserves the legislature's primary role.

Finally, she argued that a history of private discrimination should not alone establish suspect-class status. Because the Fourteenth Amendment regulates state action, she would require a demonstrated history of de jure discrimination in law before recognizing a new suspect class. She did not decide whether such a history exists for transgender people because, in her view, the lack of a sufficiently discrete and insular class independently resolved the issue.

Justice Alito

Reasoning

Justice Alito joined the Court's factual and procedural discussion and its rational-basis analysis, and he concurred in the judgment. He agreed that SB1 does not classify by sex, but used a different framework: Equal Protection sex classifications are rules that prescribe one legal standard for biological males and another for biological females.

In his view, SB1 instead classifies based on the purpose for which a minor seeks treatment. It refers to sex and may be related to sex, but it does not impose one rule on males and another on females. Nor, he concluded, is its treatment-purpose distinction a pretext for invidious discrimination between the sexes, given the law's stated focus on minors, medical risk, and uncertainty.

Justice Alito would not use Bostock in constitutional analysis. Bostock interpreted Title VII's specific language through a contested but-for-causation method, whereas Equal Protection doctrine has used a distinct inquiry into whether a law overtly classifies by sex or uses a neutral proxy as pretext for sex discrimination.

Unlike the Court, Justice Alito was willing to assume that SB1 classifies by transgender status. But he would still uphold it because transgender status, in his view, is not a suspect or quasi-suspect class. He emphasized the asserted lack of immutability, readily visible group membership, a sharply defined class, pervasive historical legal discrimination comparable to racial or sex discrimination, and exclusion from the political process.

Dissents

Justice Sotomayor

Reasoning

Justice Sotomayor, joined fully by Justice Jackson and in Parts I through IV by Justice Kagan, argued that SB1 facially classifies by sex. The law permits medications when they help a minor's appearance conform to sex identified at birth, but prohibits the same medications when they help a minor's appearance diverge from that sex. In her view, a patient's sex therefore determines access to treatment.

She illustrated the point with adolescents distressed by facial hair or breast development. A physician may prescribe hormones or puberty blockers to make an adolescent's appearance more consistent with the sex assigned at birth, but cannot prescribe the same medication to relieve comparable distress when the treatment would make the adolescent appear inconsistent with that sex. That is a sex-based distinction requiring intermediate scrutiny.

Justice Sotomayor rejected the majority's conclusion that a medical treatment must be defined by both a drug and its diagnosis. SB1 itself makes the diagnosis turn on sex consistency, she argued. Changing a patient's sex can change whether the same physical feature is deemed a treatable abnormality or gender dysphoria, making sex at least one but-for cause of the legal outcome under Bostock's reasoning.

She also concluded that SB1 expressly discriminates on the basis of transgender status because the statute targets minors who identify with or live as an identity inconsistent with their sex. She criticized the majority's reliance on Geduldig's pregnancy analysis and maintained that transgender people bear the hallmarks of a quasi-suspect class: a history of discrimination, an identity unrelated to ability to contribute to society, and political underrepresentation.

Justice Sotomayor did not deny Tennessee's important interest in protecting minors' health. But intermediate scrutiny, she explained, is the doctrine that tests whether a sex-based rule genuinely advances that interest or instead rests on stereotype or prejudice. She would have required Tennessee to show that its categorical prohibition is substantially related to protecting minors, and she would have remanded for that inquiry rather than allow rational-basis review to decide the case.

Justice Kagan

Reasoning

Justice Kagan joined the portions of Justice Sotomayor's dissent explaining why SB1 classifies by sex and transgender status and therefore requires heightened scrutiny. She agreed that the majority wrongly avoided the constitutional test designed to identify unfounded or invidious sex discrimination.

She did not join the portion of the dissent discussing how SB1 might fare under intermediate scrutiny. Because the Sixth Circuit applied only rational-basis review, and because the factual evidence concerning the treatments is extensive and disputed, she would not resolve the merits of heightened scrutiny in the first instance. She would instead remand for the lower courts to apply the proper standard.