Supreme Court upholds Tennessee law restricting gender-affirming care for transgender minors

Washington — The Supreme Court on Wednesday upheld a Tennessee law that restricts access to gender-affirming care for minors experiencing gender dysphoria, a decision that is likely to have broad implications for access to medical treatments for transgender youth in half of the country.

In the case of U.S. v. Skrmetti, high court ruled 6-3 to reject the challenge brought by the Biden administration, three families and a physician who had argued that Tennessee’s law violated the Constitution’s guarantee of equal protection under the law. The court concluded that the state’s measure, which is known as SB1 and was enacted in 2023, does not run afoul of the 14th Amendment.

“Our role is not ‘to judge the wisdom, fairness, or logic’ of the law before us, but only to ensure that it does not violate the equal protection guarantee of the Fourteenth Amendment. Having concluded it does not, we leave questions regarding its policy to the people, their elected representatives, and the democratic process,” Chief Justice John Roberts wrote.

The court’s majority found that Tennessee’s law is not subject to a heightened level of judicial review and satisfies the most deferential standard, known as rational basis.

“We are asked to decide whether SB 1 is subject to heightened scrutiny under the Equal Protection Clause,” Roberts wrote. “We hold it is not. SB1 does not classify on the bases that warrant heightened review.”

The three liberal justices, Sonia Sotomayor, Elena Kagan and Ketanji Brown Jackson, were in dissent. Sotomayor read her dissent from the bench.

The court, Sotomayor wrote, “obfuscates a sex classification that is plain on the face of this statute, all to avoid the mere possibility that a different court could strike down SB1, or categorical healthcare bans like it.”

Joined in her dissent by Kagan and Jackson, she continued: “The court’s willingness to do so here does irrevocable damage to the Equal Protection Clause and invites legislatures to engage in discrimination by hiding blatant sex classifications in plain sight. It also authorizes, without second thought, untold harm to transgender children and the parents and families who love them.”

The Tennessee law

Tennessee’s law prohibits medical treatments like puberty blockers or hormone therapy for transgender adolescents under the age of 18. The state is one of 25 with laws that seek to restrict access to gender-affirming care for young people diagnosed with gender dysphoria.

The case, U.S. v. Skrmetti, marked the first in which the Supreme Court stepped into the politically charged debate over health care for transgender youth. In addition to the state prohibitions, President Trump has issued executive orders that address what he calls “gender ideology.” One declares that it is the federal government’s policy to recognize “two sexes, male and the female,” and the second threatens federal funding for medical institutions that offer gender-affirming care to young people under the age of 18.

Mr. Trump’s proposals are being challenged in the federal courts.

Known as SB1, Tennessee’s law prevents health care providers from administering puberty blockers or hormone therapy if they’re meant to enable “a minor to identify with, or live as, a purported identity inconsistent with the minor’s sex.” The state had argued that it has a “compelling interest in encouraging minors to appreciate their sex, particularly as they undergo puberty,” and in barring treatments that “might encourage minors to become disdainful of their sex.” 

Shortly before the law took effect, three families with transgender children and a physician who provides the treatments to patients with gender dysphoria challenged the ban in federal court, arguing it is unconstitutional. The Biden administration then intervened in the case. 

A federal district court blocked the law, finding that it discriminates based on sex and transgender status. A divided panel of judges on the U.S. Court of Appeals for the 6th Circuit then reversed that decision and allowed Tennessee’s ban to take effect while legal proceedings continued.

The appeals court evaluated the law under rational-basis review, the most deferential of the tiers of judicial scrutiny. But the Biden administration and the families had argued Tennessee’s ban should be subject to a more stringent level of review, known as heightened scrutiny, because it draws lines based on sex and discriminates based on transgender status.

But Tennessee had argued that the state aims to protect young people from the consequences of the medical treatments, which it said are risky and unproven. The state said it was setting age- and use-based limits on medical care and exercising its authority to regulate medicine.

Access to gender-affirming care has become a flashpoint in the culture wars, as half of the states have in recent years enacted laws that limit the availability of the medical interventions. Many of those same states have also enacted measures prohibiting transgender athletes from competing in women’s sports.

The court’s decision

The Supreme Court’s conservative majority found that Tennessee’s law classifies on the basis of age and medical use, since treatments like puberty blockers and hormones can be administered to treat certain conditions, but not gender dysphoria, gender identity disorder or gender incongruence.

Classifications that turn on age or medical use are subject to only rational-basis review, the least demanding level of judicial review, it said.

“Under SB 1, no minor may be administered puberty blockers or hormones to treat gender dysphoria, gender identity disorder, or gender incongruence; minors of any sex may be administered puberty blockers or hormones for other purposes,” Roberts wrote.

The majority said that Tennessee had “plausible reasons” for restricting access to gender-affirming care that brought its inquiry over the law’s constitutionality to an end, namely concerns about the health risks. The justices said they wouldn’t second-guess the legislature over the lines that the ban draws.

“Recent developments only underscore the need for legislative flexibility in this area,” Roberts wrote, pointing to a report from England’s National Health Service that evaluated the evidence regarding the use of puberty blockers and hormones and characterized it as “remarkably weak.”

“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,” he wrote. “The voices in these debates raise sincere concerns; the implications for all are profound. The Equal Protection Clause does not resolve these disagreements. Nor does it afford us license to decide them as we see best.”

Roberts concluded that the court’s role is only to ensure that the law does not violate the Constitution’s guarantee of equal protection.