On June 18, 2025, the U.S. Supreme Court issued its opinion in the closely watched case of United States v. Skrmetti. In this 6-3 opinion, the Supreme Court upheld Tennessee’s legislation blocking gender-affirming care, holding that Tennessee Senate Bill 1 (SB1 or the Bill), titled Prohibition on Medical Procedures Performed on Minors Related to Sexual Identity, does not violate the Equal Protection Clause of the Fourteenth Amendment.
Senate Bill 1
SB1 prohibits healthcare providers from administering, performing, or offering to administer or perform a medical procedure if the procedure is for the purpose of “[e]nabling a minor to identify with, or live as, a purported identity inconsistent with the minor’s sex,” or “[t]reating purported discomfort or distress from a discordance between the minor’s sex and asserted identity.” Tenn. Code § 68-33-103(a). The Bill, however, allows providers to prescribe, administer, or dispense the medications for other reasons, including treating a minor’s congenital defect, precocious puberty, disease, or physical injury.
The Bill is enforced in three ways: (1) through a private right of action that allows an injured minor or nonconsenting parent of an injured minor to sue the healthcare provider; (2) authorizing the Tennessee Attorney General to bring an action against a healthcare provider to “enjoin further violations, to disgorge any profits received due to the medical procedure, and to recover a civil penalty of [$25,000] per violation”; and (3) permitting Tennessee regulatory authorities to initiate remedial action against healthcare providers who violate the law’s prohibitions. See Tenn. Code §§ 668-33-104, 105, 106.
Procedural History
Three transgender minors, their parents, and a physician (collectively, Plaintiffs) filed suit in the United States District Court for the Middle District of Tennessee challenging the constitutionality of SB1, contending that SB1 violated the Equal Protection Clause of the Fourteenth Amendment and was therefore unconstitutional. The district court concluded that Plaintiffs lacked standing to challenge SB1’s prohibition on sex transition surgery but determined that Plaintiffs could succeed on their challenge to SB1’s prohibition on puberty blockers and hormones. The district court granted a partial injunction, determining that transgender individuals were a quasi-suspect class and that the Bill was unlikely to survive intermediate scrutiny.
On appeal, the Sixth Circuit reversed, finding that rational basis review was appropriate and that the law satisfied that standard. The Sixth Circuit held that SB1 did not classify on the basis of sex, because the law applied equally to all minors, regardless of sex. The court then declined to categorize transgender individuals as a suspect class and applied rational basis review, concluding that Tennessee offered considerable evidence in support of its reasoning for introducing the bill and upheld the constitutionality of SB1.
The Supreme Court’s Decision
Chief Justice Roberts wrote the majority opinion, which was joined in full by Justices Thomas, Gorsuch, Kavanaugh, and Barrett and partially joined by Justice Alito.
1. SB1 Does Not Classify on the Basis of Sex
In upholding the constitutionality of SB1, Chief Justice Roberts highlighted the fact that SB1 creates two classifications: (1) classification on the basis of age by only applying to minors, and (2) classification on the basis of medical use by permitting puberty blockers or hormones to be prescribed only in certain situations. Because neither of these classifications warrant heightened constitutional scrutiny, the Court applied rational basis review to hold that SB1 does not violate the Equal Protection Clause.
The majority opinion rejected arguments that SB1 classified on the basis of sex, which would subject SB1’s provisions to heightened scrutiny. Chief Justice Roberts explained that the Supreme Court “has never suggested that mere reference to sex is sufficient to trigger heightened scrutiny,” especially in the medical context.
The Court offered an explanation as to how SB1 does not classify on sex. The Court rejected Plaintiffs’ argument that “SB1 prohibits certain treatments for minors of one sex while allowing those same treatments for minors of the opposite sex.” Per the Court, “[w]hen properly understood from the perspective of the indications that puberty blockers and hormones treat, SB1 clearly does not classify on the basis of sex.” For example, when “a transgender boy (whose biological sex is female) takes puberty blockers to treat his gender incongruence, he receives a different medical treatment than a boy whose biological sex is male who takes puberty blockers to treat his precocious puberty.” Therefore, per the Court’s reasoning, whether a minor receives puberty blockers tuns on what medical condition the puberty blockers will be treating, not on the sex of the minor.
In explaining its holding, the Court compared SB1 to a California insurance program addressed in Geduldig v. Aiello, 417 U.S. 484 (1974). In Geduldig, the Court analyzed the constitutionality of a California insurance program that excluded coverage for certain disabilities resulting from pregnancy. The Court held that the program did not discriminate on the basis of sex because the insurance program “divided potential recipients into two groups: ‘pregnant women and nonpregnant persons,’” so the program could not discriminate on sex because women were in both groups. According to the Court, SB1 creates similar groups—one includes only transgender individuals and the other includes both transgender and non-transgender individuals. Because transgender individuals are in both groups, the Court explained that “there is a ‘lack of identity’ between transgender status and the excluded medical diagnoses.”
2. Court Punts on Question of Whether Transgender Individuals Constitute a Quasi-Suspect Class
Although the majority made it clear that the Court was not going to address the question of whether transgender individuals are a suspect of quasi-suspect class, the concurring and dissenting opinions appear to shed light on how the Court may view the question.
Justice Barrett’s concurring opinion, joined by Justice Thomas, focused on her determination that transgender individuals are not a quasi-suspect class. She explained that the Supreme Court has “never embraced a new suspect class under [the test derived from United States v. Carolene Products Co., 304 U.S. 144, 152–53 n.4 (1938)].” Although only dicta, Justice Barrett wrote that the Sixth Circuit was right to hold that transgender individuals are not a suspect class, concluding that: “In future cases, however, [she] would not recognize a new suspect class absent a demonstrated history of de jure discrimination.”
Justice Alito’s concurring opinion reaches the same conclusion, noting that this question is one that “has divided the Courts of Appeals, and if we do not confront it now, we will almost certainly be required to do so very soon.” He makes his opinion on the question clear: “In my view, transgender status does not qualify under our precedents as a suspect or ‘quasi-suspect’ class.”
Justice Sotomayor took a different approach in her dissent, stating there should be no “serious dispute that transgender persons bear the hallmarks of a quasi-suspect class.”
However, the majority’s determination that this case does not require the question to be addressed certainly leaves the issue up for debate.
3. Does Bostock Apply?
The Court also addressed how its holding in Bostock v. Clayton County, 590 U.S. 644 (2020) affected its analysis of SB1. The 2020 landmark decision 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.” Bostock, 590 U.S. at 650–62, 654–59.
In writing for the majority, Chief Justice Roberts explained that the Court has not yet considered whether Bostock’s reasoning applies beyond the Title VII context, and that it does not need to address that question here. In dicta, however, he explains that SB1 would survive under Bostock’s reasoning because “sex is simply not a but-for cause for SB1’s operation.”
Justice Alito takes a similar approach in his concurring opinion, explaining that the “Equal Protection Clause does not contain the same wording as Title VII, and our cases have never held that Bostock’s methodology applies in cases in which a law is challenged as an unconstitutional sex classification.”
4. SB1 Survives Rational Basis Review
The Court’s opinion then subjects SB1’s provisions to the rational basis inquiry. The Court concluded that “SB1 clearly meets this standard” and pointed to the numerous findings by Tennessee’s General Assembly that the provision of gender-affirming care to minors could lead to negative, irreversible consequences.
Conclusion
The majority opinion ends with a note recognizing the public policy implications of its opinion: “This case carries with it the weight of fierce scientific and policy debates about the safety, efficacy, and propriety of medical treatments in an evolving field. The voices in these debates raise sincere concerns; the implications for all are profound.”
The Supreme Court’s full decision can be found here.
