On June 18, 2025, the Supreme Court upheld Tennessee’s ban on puberty blockers and hormone treatments for transgender minors, ruling 6–3 in United States v. Skrmetti that the law does not violate the Fourteenth Amendment’s Equal Protection Clause. The trans Supreme Court case turned on a single question: does a state law restricting these treatments discriminate based on sex? The majority said no. It found that Tennessee’s law classifies patients by age and by medical purpose rather than by sex, so the state only had to show a rational reason for the restriction rather than clear the tougher standard courts apply to sex-based laws.1Supreme Court of the United States. United States v. Skrmetti The decision leaves similar bans in roughly two dozen other states on firm federal constitutional footing.
What Tennessee’s Law Actually Bans
Tennessee Senate Bill 1 prohibits healthcare providers from giving minors medical treatment intended to help them identify as a gender inconsistent with their biological sex or to relieve distress from that inconsistency.2Justia. Tennessee Code 68-33-103 – Prohibitions In practice, that means puberty blockers and cross-sex hormones like testosterone and estrogen are off-limits for anyone under 18 when the goal is treating gender dysphoria. The ban covers both in-person care in Tennessee and telehealth reaching minors in the state.
The same medications remain legal when prescribed for other conditions, including congenital defects, precocious puberty, physical injuries, and diseases other than gender dysphoria. The statute expressly excludes gender dysphoria, gender identity disorder, and gender incongruence from what counts as a “disease” under those exceptions.2Justia. Tennessee Code 68-33-103 – Prohibitions The law took effect July 1, 2023, with a transition period allowing existing patients to continue their specific treatments through March 31, 2024, if their doctor certified that stopping abruptly would harm them.
The Constitutional Question
The challengers were three transgender minors, their parents, a Tennessee doctor, and the U.S. Department of Justice. Their argument was that the law is inherently sex-based: a boy can receive testosterone for a congenital defect, but a girl cannot receive testosterone to treat gender dysphoria. In their view, the patient’s sex determines what medicine they can get, and any law that draws lines that way should face heightened constitutional scrutiny — a standard that requires the state to prove the restriction is substantially related to an important government interest.3Congress.gov. Intro.9.3.6 United States v. Skrmetti – Equal Protection and State Laws Limiting Medical Treatments for Minors with Gender Dysphoria
They pointed to Bostock v. Clayton County, the 2020 ruling that firing someone for being transgender is sex discrimination under Title VII of the Civil Rights Act.4Supreme Court of the United States. Bostock v. Clayton County, Georgia If that logic held in employment, they argued, it should hold when a state restricts medical care based on a mismatch between sex and gender identity.
Tennessee framed the law differently. The state said it regulates procedures, not people, and that it was exercising its traditional authority to oversee medical practice and protect children from treatments whose long-term safety it considered unsettled. Whether to permit those treatments, Tennessee argued, is a policy call for elected legislators.
How the Majority Ruled
The Court accepted Tennessee’s framing. Writing for the majority, it held that the statute classifies based on age (whether the patient is a minor) and medical use (whether the treatment targets gender dysphoria), not sex. Neither of those classifications triggers heightened review, so the Court applied rational basis review — the most deferential standard in constitutional law, which asks only whether the legislature had a rational reason for the rule.1Supreme Court of the United States. United States v. Skrmetti
Under that standard, the law survived easily. The Court accepted Tennessee’s stated interest in protecting children’s health given what it described as unsettled evidence about the treatments, and declined to weigh in on the underlying medicine, pointing to “fierce scientific and policy debates” that it said were not the Court’s to resolve.5Congress.gov. United States v. Skrmetti – Supreme Court Affirms State Ban
The majority also sidestepped a broader question: whether transgender people count as a “quasi-suspect class” entitled to special constitutional protection. It reasoned that the law targets specific diagnoses, not specific people, and since not every transgender minor seeks the prohibited treatments, the law’s reach does not line up cleanly with transgender status.1Supreme Court of the United States. United States v. Skrmetti
On Bostock, the Court drew a line. In employment, changing an employee’s sex would change whether they got fired, which made sex the decisive factor. Here, the majority reasoned, changing a patient’s sex would not change the result: a transgender boy cannot get testosterone for gender dysphoria, and a cisgender boy cannot get testosterone for gender dysphoria either. The diagnosis controls, not the sex. The Court explicitly left open whether Bostock‘s reasoning applies outside Title VII at all.1Supreme Court of the United States. United States v. Skrmetti
What the Dissent Argued
Justice Sotomayor wrote the main dissent, joined in full by Justice Jackson and in part by Justice Kagan. She argued the law plainly turns on sex because it permits hormones that align a minor’s appearance with their birth sex while barring the same medications used for the opposite purpose. She compared the law to a hypothetical rule barring religious services inconsistent with a child’s birth religion: whether the activity is allowed depends entirely on an innate characteristic. Sotomayor said the majority’s use of rational basis review was the first time in 50 years the Court had applied such deferential review to legislation that in her view explicitly differentiates by sex, and she accused the majority of stepping back from the Court’s role as a check on discrimination. Justice Kagan filed a shorter separate dissent.1Supreme Court of the United States. United States v. Skrmetti
Why the Court Took the Case
The Court agreed to hear Skrmetti largely because federal appeals courts had split on the question. The Sixth Circuit reversed a lower court’s injunction against Tennessee’s law, holding that the ban did not trigger heightened scrutiny and survived rational basis review.1Supreme Court of the United States. United States v. Skrmetti The Eighth Circuit went the other way on Arkansas’s similar law in Brandt v. Rutledge, ruling that the ban discriminated on the basis of sex, applying heightened scrutiny, and finding the state had not shown the restriction was substantially related to protecting children.6Justia. Dylan Brandt v. Leslie Rutledge With the constitutionality of the same kind of law depending on the region, the Court granted review.
What the Decision Means for Other States
At the time of the ruling, 27 states had enacted laws restricting gender-affirming medical care for minors. Skrmetti effectively validates bans in 25 of them, because applying rational basis review makes these laws much harder to strike down on federal equal protection grounds.
Two states are exceptions. A federal court blocked Arkansas’s ban partly on due process grounds — a claim that the law strips parents of the right to make medical decisions for their children — and Skrmetti did not address that separate argument. Montana’s ban is blocked under the state’s own constitution, which the Supreme Court’s reading of the federal Equal Protection Clause does not touch. Bans in Arizona and New Hampshire, which cover only surgical procedures rather than hormone treatments, were not directly at issue and remain in effect on their own terms.
The ruling does not require any state to restrict these treatments. States that permit gender-affirming care for minors can continue to. What it does is remove the strongest federal constitutional challenge to state bans, leaving access to this care determined largely by where a family lives.