On June 18, 2025, the Supreme Court decided U.S .v. Skrmetti, a case about a Tennessee law banning gender-affirming hormone therapies for transgender youth (SB-1), which was challenged as violating the Equal Protection Clause of the U.S. Constitution by discriminating based on sex and transgender status. Chief Justice Roberts, writing for a 6-3 conservative majority, held that the state only needed to show a “rational basis” for the law, and allowed SB-1 to go into effect, banning hormone therapies for transgender youth in that state. Although the decision is hugely consequential for transgender children, their families, and friends, it leaves unanswered important constitutional questions about protections for transgender people. Justice Sotomayor, joined by Justices Kagan and Jackson, dissented.
The ruling allows for discrimination against transgender youth in healthcare based on the majority’s finding that SB-1 merely makes age and medical distinctions by barring the use of hormone therapies for youth with gender dysphoria. The majority does not reach the foundational constitutional questions of whether laws targeting transgender people violate equal protection and whether laws drawing distinctions based on transgender status are subject to the same “heightened scrutiny” (meaning the court requires a stronger justification for such laws) that has always previously been applied to laws that differentiate based on sex. Rather, the majority reasons that SB-1 does not rely on sex-based classifications – it just “prohibits healthcare providers from administering puberty blockers or hormones to minors for certain medical uses, regardless of a minor’s sex.” U.S. v. Skrmetti, 605 U.S. ___ (2025), slip op. 10.
The dissent points out the inherent contradiction in claiming that discrimination based on “gender dysphoria” is somehow distinct from discrimination based on sex: 2 “In addition to discriminating against transgender adolescents, who by definition ‘identify with’ an identity “inconsistent” with their sex, that law conditions the availability of medications on a patient’s sex. Male (but not female) adolescents can receive medicines that help them look like boys, and female (but not male) adolescents can receive medicines that help them look like girls.” Sotomayor dissent, slip op. 2.
Justice Sotomayor illustrates the point with this example:
Consider the mother who contacts a Tennessee doctor, concerned that her adolescent child has begun growing unwanted facial hair. This hair growth, the mother reports, has spurred significant distress because it makes her child look unduly masculine. The doctor’s next step depends on the adolescent’s sex. If the patient was identified as female at birth, SB1 allows the physician to alleviate her distress with testosterone suppressants. What if the adolescent was identified male at birth, however? SB1 precludes the patient from receiving the same medicine. Id. at 11.
While the majority opinion’s strained reasoning is dubious and draws on questionable prior precedent that declined to find pregnancy related to sex, the way in which the case was resolved leaves open the possibility of other challenges to laws that restrict gender-affirming care and otherwise discriminate against transgender people.
Questions & Answers
What is the immediate impact of this case?
This decision will have devastating impacts for transgender youth, their parents, and medical providers. It means that whether youth can access gender-affirming care, even with parental consent, will depend on where they live. The ruling does not impact care in states without bans. However, in addition to Tennessee, twenty-six other states have enacted bans on gender-affirming care for minors. In two of those states – Montana and Arkansas – existing court orders continue to prevent those bans from going into effect. Cases challenging bans in other states will continue and are likely to make their way up to the Supreme Court to consider this issue again.
The harm to transgender children and their families in states with bans is great. As the dissent puts it, “access to care can be a question of life or death.” Id. at 4. The American Academy of Pediatrics, American Medical Association, American Psychiatric Association, American Psychological Association, and American Academy of Child Adolescent Psychiatry all agree that care for gender dysphoria is appropriate and medically necessary. Id. In states with bans, families are denied basic care that has been shown to “meaningfully improve the health and wellbeing of transgender adolescents, reducing anxiety, depression, suicidal ideation, and (for some patients) the need for more invasive surgical treatments later in life.” Id. at 5 (cit. om.).
Although the ruling heightens anxieties for transgender youth and their families, advocates for transgender rights have made clear that they will not be deterred. Chase Strangio, Co-Director of the ACLU’s LGBTQ & HIV Project, who argued the case on behalf of the challengers, said: “We are as determined as ever to fight for the dignity and equality of every transgender person and we will continue to do so with defiant strength, a restless resolve, and a lasting commitment to our families, our communities, and the freedom we all deserve.”
What does this mean for Trump’s attempt to ban gender-affirming care for people under 19?
On January 28, 2025, President Trump issued an executive order that seeks to prevent transgender and intersex youth from accessing recommended health care by removing coverage for gender-affirming care from federal health insurance policies, modifying requirements under the Affordable Care Act, and preventing hospitals or other medical providers who accept Medicare or Medicaid (or who receive federal funding for research or education) from providing gender-affirming care of any kind to people under the age of 19. Federal lawsuits challenging this executive order are ongoing. Courts deciding those cases will take the Skrmetti decision into account, but the plaintiffs in those cases continue to have strong arguments that Trump’s nationwide restrictions constitute an unlawful exercise of power, and they can point to the Administration’s demonstrations of animus and overt cruelty toward transgender people as violating constitutional equal protection. There is strong precedent that attacks targeting a disfavored minority group based on animus violate equal protection.
Federal lawsuits challenging this executive order are ongoing. Courts deciding those cases will take the Skrmetti decision into account, but the plaintiffs in those cases continue to have strong arguments that Trump’s nationwide restrictions constitute an unlawful exercise of power, and they can point to the Administration’s demonstrations of animus and overt cruelty toward transgender people as violating constitutional equal protection. There is strong precedent that attacks targeting a disfavored minority group based on animus violate equal protection.
What does this mean for other cases about transgender rights, such as sports bans and bathroom bans?
Because the Court found that the Tennessee law drew distinctions based on age and medical treatment, the decision does not directly answer important questions about the rights of transgender people in many other important contexts, like youth sports and bathroom access.
The Court also declined to answer the question of whether its decision in Bostock v. Clayton County, 590 U. S. 644 (2020), applies beyond the Title VII employment context. This means that lower court decisions relying on Bostock’s reasoning that “it is impossible to discriminate against a person for being homosexual or transgender without discriminating against that individual based on sex,” id. at 660, remain good law.
What supports are available for transgender students?
NEA resources for supporting transgender students are available here: https://www.nea.org/advocating-for-change/racial-social-justice/tools-justice/lgbtqsupport-protection.
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