SCOTUS Upholds Tennessee’s Ban on Gender-Affirming Care for Minors

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Patricia Tsipras

June 26, 2025

In a 6-3 decision authored by Chief Justice Roberts, the Supreme Court of the United States upheld a Tennessee law banning gender-affirming care for minors.  United States v. Skrmetti, No. 23-477 (June 18, 2025).

The Background
In 2023, Tennessee enacted the Prohibition on Medical Procedures Performed on Minors Related to Sexual Identity.  The law prohibits healthcare providers from administering puberty blockers, hormone therapy, and sex-transition surgeries to minors (individuals under 18 years of age) for the purpose of altering their appearance or validating their gender identity when it is inconsistent with their biological sex.  The law includes exceptions for certain medical conditions.

The Lawsuit
Three transgender minors, their parents, and a doctor challenged the law under the Equal Protection Clause of the Fourteenth Amendment (i.e., no state shall deny to any person within its jurisdiction the equal protection of the laws).  They sought injunctive relief to prevent the law from taking effect.  The trial court found that the law likely infringed on parents’ fundamental rights to direct their children’s medical care and discriminated based on sex and, therefore, entered an injunction to prevent the law from taking effect.

On appeal, the United States Court of Appeals for the Sixth Circuit reversed, staying the injunction and allowing the law to take effect.

The Supreme Court granted review to determine whether the law violates the Equal Protection Clause of the Fourteenth Amendment.

SCOTUS’s Decision
The Supreme Court considered whether the law results in sex-based classification and, therefore, should be reviewed with “heightened scrutiny.”  “Heightened scrutiny” requires a showing that the law is substantially related to achieving an important government objective.  “Heightened scrutiny” is different than a “rational basis” review, which requires only that the state show that the law has a rational relation to the state’s legitimate objective.

The Court held that the Tennessee law does not classify people based on sex – a classification that would require heightened scrutiny.  Rather, the law classifies people based on age (allowing certain medical treatments for adults but not minors) and medical diagnosis (allowing puberty blockers and hormones for minors to treat certain conditions, but not to treat gender dysphoria, gender identity disorder, or gender incongruence), and that such classifications are subject merely to a rational basis review.

The Court further held that the law does not classify people based on transgender status.  Relying on prior decisions related to pregnancy, the Court explained that a state does not trigger heightened scrutiny by regulating a medical procedure that only one sex can undergo unless the regulation is a mere pretext for invidious sex discrimination, an allegation that had not been made in the case.

The Court declined to address whether its 2020 decision in Bostock v. Clayton County – where the Court held that an employer who fires an employee for being gay or transgender violates Title VII’s prohibition on discharging an individual “because of” their sex – reaches beyond the Title VII context.

The Court determined that Tennessee’s law satisfies rational basis review, which requires a court to uphold the law as long as there is “any reasonably conceivable state of facts that could provide a rational basis for the classification.”  So, what is the state’s legitimate objective?  Here, the Court noted that Tennessee

• determined that administering puberty blockers or hormones to minors to treat gender dysphoria, gender identity disorder, or gender incongruence carries risks, including irreversible sterility, increased risk of disease and illness, as well as adverse psychological consequences;
• found that minors lack the maturity to fully understand the consequences of such treatments, that many individuals have expressed regret for undergoing such treatments as minors, and that the full effects of such treatments may not yet be known; and
• noted evidence that discordance between sex and gender can be resolved through less invasive approaches.

The Court held that the law’s age-based and diagnosis-based classifications are rationally related to these findings and the state’s objective of protecting minors’ health and welfare.

The Court concluded by directing questions regarding the law’s policy to the people, their elected representatives, and the democratic process, as the Court believes that its role is only to ensure that the law does not violate the Equal Protection Clause, not to judge the wisdom, fairness, or logic of the law.

Justice Sotomayor, joined by Justice Jackson, dissented, stating that the law classifies individuals based on sex, the Court should use heightened scrutiny, and the law would fail under heightened scrutiny.  Justice Kagan filed a separate dissent to clarify she has no conclusion about whether the law would satisfy heightened scrutiny.

Takeaways
Over 25 states have enacted gender-affirming care bans for minors.  The Supreme Court’s ruling in Skrmetti may mean that most of those bans will stand, assuming that those states articulated the same types of objectives.  However, keep in mind that the Court considered this case in connection only with the Equal Protection Clause, while many other bans are being challenged on other grounds (e.g., Due Process protections).

This newsletter is designed to provide one perspective regarding recent legal developments, and is not intended to serve as legal advice, nor does it establish an attorney-client relationship with any reader of the article where one does not exist.  Always consult an attorney with specific legal issues.