In a significant ruling on June 18, 2025, the U.S. Supreme Court delivered a 6-3 decision in the case of United States v. Skrmetti, affirming a Tennessee law (SB1) that bans gender-affirming care for minors. The Court ruled that this law does not violate the Equal Protection Clause of the Fourteenth Amendment of the U.S. Constitution.
The decision came amid growing contention surrounding laws restricting gender-affirming care across various states. The Supreme Court’s review of Skrmetti addressed a crucial split among circuits regarding the constitutionality of these bans. The central issue was whether Tennessee’s prohibition on gender-affirming care for minors discriminates based on sex or transgender status, which would trigger heightened scrutiny under the law.
In its assessment, the Court determined that the Tennessee law classifies individuals based primarily on age and medical diagnosis, thus not constituting sex-based discrimination. As a result, the Court concluded that heightened scrutiny was unnecessary and that the law adheres to the more lenient rational basis review. This standard requires the state to demonstrate only a rational relationship between the law and a legitimate government objective.
The majority opinion asserted that the law can stand under the rational basis standard, which means it would be upheld as long as there exists any conceivable state of facts providing a rational justification for the law should it be challenged.
Justices Sonia Sotomayor and Ketanji Brown Jackson dissented, arguing that the law does indeed classify individuals based on sex. They contended that heightened scrutiny should apply, and that under such scrutiny, SB1 would likely fail to meet constitutional standards. Meanwhile, Justice Elena Kagan concurred with much of Sotomayor’s dissent but issued a separate opinion stating her views on whether SB1 could withstand heightened scrutiny were not definitively concluded.
The ramifications of this ruling extend far beyond Tennessee, potentially impacting numerous states with similar bans. As of June 2025, 27 states have enacted laws restricting gender-affirming care for minors, and following the Supreme Court’s ruling, 25 of these laws remain in place. In Montana and Arkansas, however, these bans are currently blocked—Montana’s ban is halted due to issues pertaining to the state constitution, while Arkansas’s law has been found unconstitutional based on both Equal Protection and Due Process claims.
The Arkansas ruling stemmed from parents contesting the law on the grounds that it infringes upon their right to make healthcare decisions for their children. As a result of this injunction, Arkansas’s law remains blocked. Additionally, Arizona and New Hampshire have laws in place that restrict only surgical care, which were not contested in the Supreme Court decision and thus remain effective.
This ruling has left a complex landscape regarding access to gender-affirming care for minors throughout the United States. For young individuals residing in states where access was previously prohibited, the situation remains unchanged. Conversely, minors who had access to gender-affirming care before the decision continue to retain that access.
There were earlier speculations regarding the Court’s potential application of reasoning established in Bostock v. Clayton County, which broadened employment discrimination protections to include gender identity and sexual orientation. However, the Supreme Court opted not to apply Bostock’s reasoning to this case, clarifying that altering a minor’s sex or transgender status does not directly implicate the same legal considerations as in the employment context addressed in Bostock.
The Supreme Court focused specifically on the Equal Protection claims in this case. Many related challenges have been brought under various legal theories, including claims of Due Process. The case in Arkansas, which has already seen a federal district court permanently block the ban due to issues surrounding parental rights under the Due Process clause, highlights the potential for further litigation on this front.
As future legal battles unfold regarding state laws on gender-affirming care, the Supreme Court may eventually be called upon to address broader claims under Due Process or other provisions in healthcare law, such as Section 1557 of the Affordable Care Act. The continuing legal challenges underscore the ongoing debate surrounding the rights of transgender minors and the varying interpretations of constitutional protections across different states.
Ultimately, the ruling in Skrmetti contributes to the existing patchwork of regulations surrounding gender-affirming care for minors, allowing for ongoing litigation within state courts as advocates for transgender rights seek to navigate the complexities of both state and federal legal frameworks. As lawmakers and advocates respond to this ruling, the landscape of health care access for transgender youth in the U.S. remains a critical and evolving issue.
image source from:kff