The US Supreme Court on June 18, 2025 rejected a challenge under the Fourteenth Amendment’s Equal Protection Clause to Tennessee law SB1, which prohibits healthcare providers from dispensing puberty blockers, hormone replacement therapy, or similar medical treatments to adolescents in Tennessee for the purposes of treating “discomfort or distress from a discordance between the minor's sex and asserted identity.” The law in question specifically provides that such medical treatments may be administered for other purposes, such as treating congenital defects or precocious puberty, but not for purposes of treating gender dysphoria.
In the United States v. Skrmetti, the Supreme Court held that SB1’s prohibitions are not subject to the type of heightened judicial scrutiny that applies to laws that discriminate on the basis of sex or membership in another suspect or quasi‑suspect class. Instead, to comply with the Equal Protection Clause, the State of Tennessee need only demonstrate a “rational basis” for SB1. The Court concluded that the legislature’s proffered concerns about whether these types of medical treatments are necessary or beneficial when used to provide gender-affirming care to minors satisfied that minimal level of scrutiny.
The plaintiffs challenging SB1 are transgender minors, their families, and a healthcare provider, who claim SB1 violates the Equal Protection Clause of the Fourteenth Amendment. Plaintiffs argued that because SB1 only prohibits treatment to address an incongruity between gender identity and sex assigned at birth, it necessarily reflects a “sex-based classification.” Under long-standing Supreme Court precedent, if a statute’s application depends on the sex of the person to whom it is applied, the state must satisfy heightened constitutional scrutiny and demonstrate the law furthers a substantial governmental interest to comport with the Equal Protection Clause. [1]
In Skrmetti, the Supreme Court rejected the argument that SB1 incorporates a “sex-based classification.” The Court held that the application of SB1 is based on the age of the patient and the purpose of the medical treatment, not the sex of the patient. While the Court acknowledged SB1 defines the proscribed purposes by referencing the patient’s sex, it reasoned that “the Court has never suggested that mere reference to sex is sufficient to trigger heightened scrutiny.”
In the alternative, the plaintiffs argued that the Court should deem transgender individuals a quasi-suspect class for purposes of the Equal Protection Clause, such that laws discriminating against them would be subject to heightened scrutiny. This would have been the first time the Supreme Court addressed the question of whether transgender people are a class entitled to heightened protection under the Fourteenth Amendment, which is presently the subject of an inter-circuit split.
The Court held that it did not need to decide whether transgender individuals are a “quasi-suspect class.” The Court acknowledged that SB1’s purpose is “banning the use of certain medical procedures for treating transgender minors,” but nevertheless concluded that SB1’s application does not turn on whether a person is transgender. The Court reasoned that “SB1 does not exclude any individual from medical treatments on the basis of transgender status but rather removes one set of diagnoses—gender dysphoria, gender identity disorder, and gender incongruence—from the range of treatable conditions.”
While those are diagnoses uniquely experienced by transgender people, the Court concluded that the law does not discriminate on the basis of transgender identity because a transgender minor could still receive the proscribed medical treatments for some other purpose.
The plaintiffs in Skrmetti further argued that the Supreme Court’s decision in Bostock v. Clayton County[2] supported their argument that SB1 is ultimately a sex-based classification and subject to heightened scrutiny. In Bostock, the Supreme Court held that discrimination based on sexuality or gender identity violates Title VII because, “[f]or an employer to discriminate against employees for being homosexual or transgender, the employer must intentionally discriminate against individual men and women in part because of sex.” [3]
The Court reaffirmed the reasoning in Bostock as applied to Title VII but declined to apply it to Skrmetti. The Court noted that “[w]e have not yet considered whether Bostock’s reasoning reaches beyond the Title VII context” and “we need not do so here” because, unlike in Bostock, the operation of SB1 is not necessarily dependent on gender. The Court reasoned that changing the sex of the employee in Bostock changed the employment outcome (e.g., a man married to a man would be terminated, but a woman married to a man would not), whereas changing the sex of a minor would not necessarily change their access to treatment under SB1.
The Court’s decision in Skrmetti will likely be applied by lower courts to similar legislation enacted or proposed in more than two dozen other states. These laws have profound implications for transgender minors and their families who reside in those states. They also create serious regulatory and operational considerations for healthcare providers involved in the non-static field of gender-affirming care.
This includes, but is not limited to, providers of primary care services, behavioral health services, surgical services, pharmacy services, and regional and national telehealth services. These considerations are heightened for providers whose systems span multiple states, which may be subject to inconsistent state regulations. Indeed, in direct contrast to laws like SB1, some states have enacted “shield” laws that protect access to gender-affirming care as opposed to limiting it.
SB1 also creates a private right of action, which allows minors and their parents to sue healthcare providers for alleged violations of SB1. Laws in other states go further. For example, Mississippi has created a private right of action against anyone who “aids and abets” the provision of gender-affirming care to a minor, with fewer restrictions on who may file suit. [4] This is an emergent area of law, with very little precedent on who may be found liable under such statutes and whether liability could extend beyond health care providers to other persons and entities involved in the provision of gender-affirming care (e.g., health plans, insurers, and pharmaceutical manufacturers).
It is important to note that the Supreme Court’s decision in Skrmetti only means that states can lawfully enact legislation like SB1 without violating the Equal Protection Clause. It does not require that states adopt similar policies or otherwise restrict access to gender-affirming care for minors. It also does not address the scope and enforceability of private rights of action, nor foreclose potential defenses that could be asserted to such an action under federal or state law.
For the avoidance of doubt, in states where no legislation like SB1 has been enacted, healthcare providers can continue to provide the types of services that are restricted in Tennessee; pharmaceutical and medical device companies can continue to develop and sell products that may be used for gender-affirming care to providers in states where such treatment is legal; and employers and insurance companies can continue to provide health insurance benefits for gender-affirming care in states where such procedures are legal.
Visit our US Administration Policies and Priorities resource center and subscribe to our mailing list for the latest on programming, guidance, and current legal and business developments.
If you have any questions or would like more information on the issues discussed in this LawFlash, please contact any of the following: