Skrmetti ruling: the Supreme Court and trans healthcare for minors

On June 18, 2025, the United States Supreme Court issued the most significant ruling on transgender rights since Bostock v. Clayton County in 2020. In the case United States v. Skrmetti (docket 23-477), six justices to three held that Tennessee’s ban on gender-affirming care for minors does not violate the Equal Protection Clause of the Fourteenth Amendment [1]. It is the first time in history that the Supreme Court has ruled on treatment for gender dysphoria. The consequences extend well beyond Tennessee: 25 of 27 state bans are now fully enforceable, and approximately 120,400 trans adolescents live in states where they cannot access puberty blockers or hormone therapy [3][4].

Tennessee’s law: Senate Bill 1

The law at the center of the case is called Senate Bill 1 (SB1). Passed by the Tennessee legislature and signed by Governor Bill Lee on March 2, 2023, it took effect on July 1 of the same year [1][9].

What it bans

SB1 prohibits healthcare professionals from prescribing, administering, or dispensing puberty blockers and hormone therapy to any minor if the treatment is intended to “enable the minor to identify with, or live as, a purported identity inconsistent with the minor’s biological sex” [1]. The ban extends to telemedicine and covers any treatment aimed at alleviating distress arising from the discordance between the sex assigned at birth and gender identity.

The penalties

The consequences for healthcare professionals who violate the law are threefold [9][14]. First: a civil penalty of up to $25,000 per prohibited treatment, with the possibility of action by the Tennessee Attorney General. Second: professional disciplinary sanctions under Title 63 of the Tennessee Code, which can include suspension or revocation of medical licensure. Third: a private civil action allowing the minor or parents who did not give consent to sue the professional.

The exception that reveals the discrimination

A central element of the case concerns what SB1 does not ban. The same drugs — puberty blockers and hormones — remain perfectly legal when prescribed to minors for other medical conditions: precocious puberty, congenital defects, diseases, or physical injuries [1][3]. A cisgender girl can receive puberty blockers for precocious puberty. A cisgender boy can receive testosterone for hypogonadism. But a trans adolescent cannot receive the exact same drugs for gender dysphoria. This distinction — same drugs, same minor patients, different medical purpose — is at the heart of the entire legal debate over the discriminatory nature of the law.

The judicial path

The case went through three levels of adjudication in just over two years.

The initial challenge

On April 20, 2023, Lambda Legal, the ACLU, and the ACLU of Tennessee filed a challenge in the federal court of the Middle District of Tennessee on behalf of three families and a doctor [13][14]. The lead plaintiffs were Samantha and Brian Williams of Nashville and their fifteen-year-old transgender daughter, identified as L.W., along with two other families who filed anonymously and Dr. Susan Lacy of Memphis. The argument: SB1 violates the Equal Protection Clause of the Fourteenth Amendment because it discriminates on the basis of sex.

On April 26, 2023, the United States Department of Justice, under the Biden administration, filed a motion to intervene in the case as a plaintiff, arguing that SB1 violates federal law [14]. Judge Eli Richardson granted the motion on May 16, 2023. From that point, the case assumed the name United States v. Skrmetti, after Tennessee Attorney General Jonathan Skrmetti.

The district court blocks the law

On June 28, 2023, the district court issued a preliminary injunction blocking the enforcement of SB1, with the exception of the private right of action and the surgery ban [1][13]. The judge found that the plaintiffs had demonstrated a likelihood of success on the merits of their Equal Protection claim.

The Sixth Circuit reverses the decision

Tennessee’s response came quickly. In July 2023, the Sixth Circuit Court of Appeals stayed the injunction with a 2-1 vote, with Judge Jeffrey Sutton writing for the majority [1][2]. On September 28, 2023, the same panel reversed the district court’s preliminary injunction, applying rational basis review and concluding that SB1 does not classify on the basis of sex [2].

The Supreme Court takes the case

On June 24, 2024, the Supreme Court agreed to hear the case (certiorari). Oral arguments were held on December 4, 2024 [1][2]. The Biden administration argued in favor of the plaintiffs before the Court. The ruling was issued on June 18, 2025.

The majority opinion

Chief Justice John Roberts wrote the majority opinion, joined by Justices Thomas, Alito (in part), Gorsuch, Kavanaugh, and Barrett [1].

The classification: not sex, but “medical use”

The central reasoning of the majority rests on a distinction: SB1 does not classify people on the basis of sex or transgender status, but operates only two classifications — by age (allowing certain treatments for adults but not for minors) and by medical use (allowing puberty blockers and hormones for some conditions but not for others) [1][9]. According to the Court, these two classifications do not constitute suspect classes and do not require a heightened level of scrutiny.

Rational basis review

The Court applied rational basis review, the lowest standard of scrutiny in American constitutional law [1][3]. Under this standard, a law is valid if any rational basis exists to justify it. The legislature need not demonstrate that the law is the best or most effective means of achieving its objective: it is sufficient that the connection between the law and a legitimate state interest is plausible.

In this case, the Court found that Tennessee had a rational basis in wanting to regulate medical treatments for minors in a field that the majority characterized as marked by “medical uncertainty” [1]. The Court stated that state legislatures have the right to exercise caution in the face of treatments whose long-term effects are the subject of debate.

The refusal to apply Bostock

A significant passage of the opinion concerns the precedent of Bostock v. Clayton County (2020), the ruling that had established that Title VII of the Civil Rights Act protects workers from discrimination based on gender identity. The majority explicitly refused to extend Bostock’s reasoning to the context of the Equal Protection Clause, arguing that Title VII and the Fourteenth Amendment operate with different standards and purposes [1][9].

Deference to the state legislature

The Court reaffirmed the principle of deference to state legislatures in the regulation of medical practice, a concept with a direct precedent in the ruling Dobbs v. Jackson Women’s Health Organization (2022), which eliminated the federal right to abortion [1][6]. The Court emphasized that “the regulation of medical practice is ordinarily a state prerogative” and that judges should not substitute their judgment for that of legislators on healthcare policy matters.

The dissent

Justice Sonia Sotomayor wrote the dissent, joined in full by Justice Ketanji Brown Jackson, and in part (Parts I-IV) by Justice Elena Kagan [1]. Justice Kagan also wrote a separate dissent.

The law is a sex-based classification

The central argument of the dissent is direct: SB1 is a classification based on sex, regardless of how the majority defines it [1][10]. Sotomayor wrote that “sex determines access to the drugs covered by the law.” A male adolescent (but not a female) can receive drugs that help him appear as a boy. A female adolescent (but not a male) can receive drugs that help her appear as a girl. For transgender minors, exactly the opposite occurs: the same drugs, administered for the same purpose of aligning physical appearance with identity, are banned.

Heightened scrutiny was required

Sotomayor argued that, as a sex-based classification, the Court should have applied intermediate scrutiny, not rational basis review [1]. Under intermediate scrutiny, Tennessee would have had to demonstrate that SB1 serves an “important governmental interest” and that the means chosen is “substantially related” to that interest — a significantly higher burden of proof.

Medical consensus

The dissent emphasized that the major American medical organizations — the American Academy of Pediatrics, the Endocrine Society, the American Medical Association, the American Psychological Association — recommend gender-affirming care as appropriate, evidence-based treatment for gender dysphoria in minors [1][5]. Sotomayor challenged the majority’s characterization of these treatments as uncertain, calling it a distortion of the state of the research.

“Incalculable harms”

In a passage that received widespread media coverage, Sotomayor warned that the ruling will cause “incalculable harms” to transgender minors and their families [10][12]. She added that “by refusing to apply heightened scrutiny, the majority renders transgender Americans doubly vulnerable to state-sanctioned discrimination” [1].

The immediate consequences

The effects of the ruling manifested on multiple fronts in the months that followed.

State bans become fully enforceable

Before Skrmetti, several state bans were blocked or contested in court. After the ruling, 25 of 27 state bans on gender-affirming care for minors are now fully in effect [3]. The only exceptions are Montana, where the ban is blocked on the basis of the state constitution (and not federal law, thus not directly affected by Skrmetti), and Arkansas, whose ban was still the subject of litigation at the time of the ruling [3].

Brandt v. Rutledge: Arkansas capitulates

On August 12, 2025, the Eighth Circuit Court of Appeals reversed its previous decision in the case Brandt v. Rutledge, the first case that had blocked a state ban on gender-affirming care (Arkansas’s, passed in 2021) [15]. In an en banc decision with a vote of 8 to 2, the court held that Arkansas’s Save Adolescents from Experimentation Act does not violate the Equal Protection Clause, due process, or the First Amendment. The first 13 pages of the opinion are dedicated to explaining why the case is controlled by Skrmetti [15]. Arkansas’s ban, blocked by courts for four years, is now fully in effect.

The impact on minors

According to the Williams Institute at UCLA, 120,400 transgender adolescents between the ages of 13 and 17 — 40.1% of all trans youth in that age group in the United States — live in states where gender-affirming care is banned [4]. These are adolescents whose state of residence prevents them from accessing treatments recommended by every major medical association in the country.

Extension to young adults

In some states, the Skrmetti ruling fueled proposals to extend bans beyond age 18. In Oklahoma, Texas, and South Carolina, bills were introduced that would have banned gender-affirming care up to age 26 [3]. In Texas, a bill (H.B. 4574) provided that a healthcare professional who provides gender-affirming care to a trans person under 26 could be sentenced to imprisonment and loss of medical licensure. In Oklahoma, the proposal was later scaled back to 18 after strong opposition.

State courts as the new battleground

After Skrmetti, the federal Supreme Court no longer represents a viable path for challenges based on the Equal Protection Clause. The State Court Report documented how state courts have become the new terrain of litigation [7]. In Montana, a trial court struck down a 2023 law that defined sex as two binary categories, finding that it violated the right to privacy guaranteed by the state constitution. In Texas, by contrast, the state supreme court upheld the ban, directly citing Skrmetti [7]. State constitutions offer protections that vary enormously from state to state, creating a fragmented legal landscape where geography determines rights.

The parallel with Dobbs

The Skrmetti ruling does not exist in a legal vacuum. Its legal architecture mirrors that of Dobbs v. Jackson Women’s Health Organization (2022), the ruling that eliminated the federal right to abortion established by Roe v. Wade in 1973 [6][7].

The same legal logic

Both rulings share three structural elements [6][8]. First: the application of rational basis review to issues concerning bodily autonomy, the standard that grants the maximum margin of discretion to the legislature. Second: the principle of deference to state legislatures in the regulation of medical matters that the Court considers within legislative rather than judicial competence. Third: the refusal to recognize a protected constitutional right — in the case of Dobbs, the right to abortion; in the case of Skrmetti, the right to access gender-affirming care for minors.

Tennessee explicitly cites Dobbs

In the briefs filed with the Supreme Court, Tennessee explicitly cited Dobbs to support the legitimacy of SB1 [6]. The argument: if the Court has established that states can regulate and ban abortion without violating the right to privacy or due process, the same logic applies to the regulation of gender-affirming care. The Court, in its majority opinion, accepted this analogy.

The same organizations, the same strategy

As documented by Ms. Magazine, the same organizations that led the legal strategy to overturn Roe v. Wade — in particular the Alliance Defending Freedom and the Heritage Foundation — are actively involved in promoting state bans on gender-affirming care [6]. The strategy is analogous: build a series of restrictive state laws, wait for them to be challenged in court, and bring cases before a favorable Supreme Court to obtain a national precedent.

The reaction of Reproductive Freedom for All

Reproductive Freedom for All, the organization born from the merger of NARAL Pro-Choice America, condemned the Skrmetti ruling, calling it a direct attack on bodily autonomy that “endangers vulnerable young people, their families, and their healthcare professionals” [8]. The organization drew an explicit parallel with Dobbs, arguing that both rulings “use the same legal architecture to deprive people of control over their own medical decisions” [8].

The Center for American Progress analysis

The Center for American Progress framed the Skrmetti case as a question of bodily autonomy that concerns everyone, not just transgender people [5]. After the ruling, the organization stated that the Court “put politics before science” with an opinion “full of anti-science myths that refuses to acknowledge that everyone deserves equitable access to medical care” [5]. The warning: if states can substitute themselves for healthcare professionals in decisions about gender-affirming care, the same principle can be applied to other categories of medical treatment.

Coverage in Italy

The ruling also received attention in Italian media. Gay.it called the Court’s decision “a national shock,” quoting the words of Chase Strangio, ACLU attorney and the first openly transgender lawyer to argue a case before the Supreme Court: “Today’s ruling is a devastating defeat for transgender people, for our families, and for everyone who cares about the Constitution” [10]. Tennessee Attorney General Jonathan Skrmetti instead called the decision a victory of “common sense over judicial activism” [10].

Adnkronos, through its outlet Demografica, described the case as “the first in Supreme Court history to feature treatment for gender dysphoria” [11]. Il Manifesto headlined “Healthcare denied to transgender minors,” emphasizing how the decision could “become a dangerous legal precedent” for future cases [12].

The picture after Skrmetti

The data tell the story of the ruling’s scope. Twenty-seven states have passed laws banning gender-affirming care for minors. After Skrmetti, 25 of these bans are fully enforceable [3]. Approximately 120,400 adolescents between 13 and 17 live in states where they cannot access puberty blockers or hormone therapy for gender dysphoria [4]. The Eighth Circuit has already reversed the first ban that had been blocked by a court, and others will follow [15].

On the legal front, the ruling established three principles. First: laws that distinguish medical treatments based on purpose (gender dysphoria versus other conditions) do not constitute a sex-based classification [1]. Second: rational basis review, not heightened scrutiny, applies to such laws [1]. Third: state legislatures have broad discretion in regulating medical care for minors, even when the medical community recommends treatments different from those permitted by law [1][9].

Legal challenges now shift to state courts and arguments beyond the Equal Protection Clause: due process, state constitutions, Section 1557 of the Affordable Care Act [3][7]. As the State Court Report observed, “with the federal void forcing states to chart their own course, state courts increasingly draw on their own constitutional traditions to shape the future of reproductive and transgender rights” [7].

The Skrmetti ruling does not close the debate. It redefines it, shifting it from the federal level to the state level, from the Fourteenth Amendment to local constitutions, from the Supreme Court to trial courts. The result is a country where access to medical care for transgender minors depends on the nearest state border.