United States v. Skrmetti: Ruling, Reasoning, and Dissent

In United States v. Skrmetti, decided June 18, 2025, the Supreme Court upheld Tennessee’s ban on puberty blockers and hormones for minors seeking gender-transition treatment, ruling 6–3 that the law does not violate the Equal Protection Clause of the Fourteenth Amendment. Chief Justice Roberts, writing for the majority, held that Tennessee’s Senate Bill 1 classifies by age and medical diagnosis rather than by sex or transgender status, so only rational basis review applies. Under that deferential standard, the law survives. The decision leaves in place similar restrictions in more than 20 states.¹

The Law the Court Reviewed

Tennessee’s SB1, codified at Tenn. Code Ann. § 68-33-101 through 68-33-110, bars healthcare providers from prescribing, administering, or dispensing puberty blockers or hormones to anyone under 18 when the purpose is to help the minor identify as a gender inconsistent with their biological sex, or to treat distress stemming from that inconsistency. The same drugs remain legal for minors when prescribed for other conditions: congenital defect, precocious puberty, disease, or physical injury. The statute expressly excludes gender dysphoria, gender identity disorder, and gender incongruence from the “disease” exception.²

SB1 also bans surgeries performed for the same purposes, but that provision was not before the Court because the challengers lacked standing to contest it.¹

The Question Before the Court

Transgender youth, their parents, a treating physician, and the federal government challenged SB1 as sex-based and transgender-based discrimination. The Supreme Court took the case on a single question: whether SB1 violates the Equal Protection Clause.¹

That question turned almost entirely on the level of judicial scrutiny. Under rational basis review, a law will be upheld as long as any reasonably conceivable set of facts could provide a rational basis for the classification. Under intermediate scrutiny, which applies to sex-based classifications, the state must show the law serves an important objective and is substantially related to achieving it.³ Whichever standard the Court chose was likely to decide the outcome.

Why the Majority Said the Law Is Not Sex Discrimination

The Court held that SB1 does not draw lines by sex. The law prohibits providers from administering puberty blockers or hormones to any minor for gender dysphoria, gender identity disorder, or gender incongruence, whether the patient is a boy or a girl. It permits those same treatments for any minor, again regardless of sex, when used for another qualifying condition. The distinction the statute draws is between diagnoses, not between the sexes.¹

The Department of Justice had argued that the classification is sex-based because a male minor can receive testosterone for a covered condition while a female minor cannot receive it for gender transition. The majority rejected that framing. In the Court’s view, the trigger is the diagnosis, and the diagnosis is available to a patient of either sex only when it falls within one of the permitted categories.

Why the Majority Said It Is Not Transgender-Status Discrimination

The government also argued that even if SB1 is not facially sex-based, it targets transgender minors because only they seek treatment for gender dysphoria. The majority disagreed, relying on Geduldig v. Aiello, the 1974 decision holding that a pregnancy-related classification is not automatically a sex-based one. The Court found a similar “lack of identity” here, because the group of minors who can receive puberty blockers and hormones for permitted uses includes both transgender and non-transgender patients.¹

The government’s reliance on Bostock v. Clayton County, which held that firing an employee for being transgender is sex discrimination under Title VII, also failed. The majority explained that Bostock’s but-for causation test does not translate here: if a transgender boy is denied testosterone for gender dysphoria, changing his biological sex in the hypothetical does not unlock the prescription, because he would still lack a qualifying diagnosis. The Court declined to decide whether Bostock’s reasoning applies outside Title VII at all.¹

With heightened scrutiny off the table, rational basis review applied. The Court found that Tennessee’s stated concerns about the uncertain long-term effects of these treatments on minors easily met that standard. The majority stressed that questions about the law’s wisdom belong to legislatures and voters, not judges.

The Concurring Opinions

Justice Thomas wrote separately to argue that Bostock’s reasoning should not be imported into equal protection analysis at all. The Equal Protection Clause lacks Title VII’s specific statutory language, and extending Bostock could put a wide range of state laws regulating sex-defined medical procedures under heightened scrutiny. Thomas also questioned deference to medical experts over legislatures in politically contested scientific debates.¹

Justice Barrett, joined by Thomas, addressed whether transgender status should ever be recognized as a suspect or quasi-suspect class. She argued that the set of constitutionally protected classes has been effectively closed for over four decades and that courts should not recognize a new one without a demonstrated history of formal legal discrimination against the group.¹

Justice Alito concurred in the judgment. He agreed SB1 does not classify by sex but found the transgender-status question closer, noting “a strong argument” that the law does classify on that ground while declining to resolve it. He also stated that Bostock’s reasoning does not apply to equal protection analysis.¹

The Dissent

Justice Sotomayor dissented, joined in full by Justice Jackson and in most parts by Justice Kagan. The dissenters read SB1 as a facial sex-based classification. In their view, the treatment a minor is allowed to access turns on whether the requested outcome is “inconsistent” with the minor’s biological sex, and that is a textbook sex-based distinction. An adolescent whose biological sex is female cannot receive testosterone to live as male, but an adolescent whose biological sex is male can receive testosterone for a qualifying condition.¹

The dissent also argued that the Geduldig framework should be discarded, finding SB1 unlike a pregnancy classification because the statute defines the prohibited treatments by reference to the patient’s sex. Justice Kagan filed a separate dissent as well.

What the Ruling Means

The immediate effect is that Tennessee’s law stands, and similar bans in more than 20 other states rest on firmer constitutional ground. Before Skrmetti, those laws faced ongoing equal protection challenges arguing for heightened scrutiny. The holding that rational basis review applies makes those challenges far harder to win.¹

The decision leaves several questions unresolved. The Court did not decide whether Bostock’s reasoning extends beyond Title VII to constitutional claims. It did not decide whether transgender status is a suspect or quasi-suspect classification, though Justice Barrett’s concurrence signaled significant skepticism about recognizing new protected classes. And the ruling does not touch due process arguments about parental rights to direct their children’s medical care, which were raised in the lower courts but excluded from the Court’s review. Those arguments remain available for future litigation on a different constitutional theory.

1
Supreme Court of the United States. United States v. Skrmetti
2
Tennessee State Legislature. Senate Health and Welfare Amendment to SB0001
3
Cornell Law Institute. Gender Classifications General Approach