United States v. Skrmetti and the Limits of Equal Protection for Trans Youth

On June 18, 2025, in the last weeks of a term crowded with emergency fights over the new administration, Chief Justice John Roberts announced the Court's decision in a case that had begun as a challenge brought by three Tennessee families and a doctor. Their children were transgender teenagers. Tennessee's legislature had passed a law in 2023, known in the statehouse as Senate Bill 1, that banned doctors from prescribing puberty blockers or hormones to minors to treat gender dysphoria. The families argued that the law discriminated on the basis of sex and transgender status. The federal government, under President Biden, had joined their side and then taken the case to the Supreme Court. By the time the justices ruled, a different administration was in office and the government's lawyers had changed their position. The Court ruled 6-3 for Tennessee.

In short: In United States v. Skrmetti the Supreme Court held that Tennessee's ban on puberty blockers and hormones for minors with gender dysphoria does not classify by sex or transgender status in a way that triggers heightened scrutiny, so it needs only a rational basis, which the state had. The Court left open whether transgender status is ever a protected class, and it did not decide parents' rights claims.

The law and the families

Tennessee's law is one of a wave of similar laws. By the time the case was argued, about half the states had passed restrictions on gender-affirming medical care for minors, mostly between 2021 and 2024. The specifics vary. Tennessee's version prohibits health care providers from prescribing puberty blockers or cross-sex hormones to anyone under 18 for the purpose of allowing them to identify with, or live as, a gender inconsistent with their sex at birth, or to treat distress arising from that discordance. It allows the same drugs for other conditions, such as early puberty or a congenital condition. It also gave minors already receiving treatment a short window to taper off.

The plaintiffs were families whose children had been receiving or seeking this care with the support of their doctors. They argued that the law violated the Equal Protection Clause of the Fourteenth Amendment because it classified based on sex and on transgender status, and that a parent's right to direct a child's medical care was also violated. A federal district judge blocked most of the law. The Court of Appeals for the Sixth Circuit reversed, and the Supreme Court agreed to hear only the equal protection question as the federal government had presented it.

Why the level of scrutiny decides almost everything

To understand Skrmetti, you need a short lesson in how courts review laws under the Equal Protection Clause. The level of review usually decides the case.

Most laws get rational-basis review: a law survives if it is rationally related to any legitimate government purpose. Almost everything passes. Laws that classify by race get strict scrutiny, the most demanding test: the government must show a compelling interest and a narrowly tailored means. Almost nothing passes. Laws that classify by sex get intermediate scrutiny: the government must show an exceedingly persuasive justification, with a substantial relationship to an important interest. Many sex classifications fail.

So the families' strategy was to show that Tennessee's law was a sex classification, which would trigger intermediate scrutiny. Their argument went like this: a doctor may prescribe testosterone to a boy who was identified as male at birth, for example to treat delayed puberty, but may not prescribe testosterone to a boy who was identified as female at birth to treat gender dysphoria. Change the patient's birth sex and the legality changes. That looked, to them, like a textbook sex classification. They also argued, in the alternative, that the law classified by transgender status and that transgender status should itself get heightened scrutiny.

What the majority decided

Roberts's opinion for the Court, joined by Justices Clarence Thomas, Samuel Alito, Neil Gorsuch, Brett Kavanaugh and Amy Coney Barrett, rejected both routes.

On sex, the majority said the law classifies by two things: age, since it applies only to minors, and medical use, since it bars the drugs for some diagnoses and not others. Neither of those is a sex classification. The law does not prohibit conduct for one sex that it allows for the other, the Court said; it bars the drugs for gender dysphoria for everyone under 18, whatever their sex. The majority treated the families' example as comparing two different medical purposes rather than two sexes.

On transgender status, the majority held that the law does not classify on that basis either. It drew on older cases holding that a law regulating a medical procedure only one group can undergo is not automatically a classification against that group. Because it found no transgender classification, the Court did not decide whether transgender status deserves heightened scrutiny.

The families had also relied on Bostock v. Clayton County, the 2020 decision holding that firing someone for being transgender is sex discrimination under Title VII. The majority said that even assuming Bostock's reasoning could apply to equal protection, the law would not fail it, because changing a minor's sex would not change the law's application to the use at issue. It expressly did not decide whether Bostock's logic reaches the Constitution.

Applying rational-basis review, the Court found that Tennessee had a rational basis in what it described as uncertainty in the medical evidence about the benefits and risks of these treatments for minors. Roberts noted that the law leaves the policy debate to the people and their representatives.

The concurrences and the dissent

Several justices wrote separately, and their opinions show where future fights are heading.

Justice Barrett, joined by Justice Thomas, wrote that she would hold that transgender status is not a suspect or quasi-suspect class at all, which would mean most laws treating trans people differently get only rational-basis review. Justice Alito wrote separately to similar effect. Justice Thomas also wrote to criticize what he saw as courts' excessive deference to medical associations. Those opinions do not bind lower courts, but they signal how at least three justices would answer the question the majority left open.

Justice Sonia Sotomayor wrote the principal dissent, joined by Justice Ketanji Brown Jackson and, in most parts, Justice Elena Kagan. Her central point was that the law plainly turns on sex: whether a minor can receive testosterone depends on whether the minor was identified as male or female at birth, and that is the kind of classification intermediate scrutiny exists for. She argued that the majority's reasoning would make it easy for states to discriminate by describing a sex-based rule in terms of medical purpose, and that the families' children would bear the cost. Justice Kagan wrote separately that she agreed intermediate scrutiny applied, but that she would not decide whether the law survives it, leaving that to the lower courts.

The other side's strongest case

It would be easy to write about Skrmetti as if the only question were discrimination. That would not be fair to the many people, including some who consider themselves allies of trans adults, who supported the law, and it would not help anyone persuade them.

The strongest case for laws like Tennessee's runs roughly this way. These are serious medical interventions given to children who cannot fully weigh long-term consequences, including effects on fertility and bone density. Systematic reviews of the evidence, most prominently the Cass Review commissioned by England's National Health Service and published in 2024, found the evidence base for puberty blockers and hormones in adolescents to be weak, and several European health systems have narrowed access for minors. When evidence is uncertain, the argument goes, legislatures are entitled to be cautious.

The answer that families and most major American medical associations give is also serious. Uncertainty in evidence is common across pediatric medicine, and the normal response is careful clinical judgment by doctors, patients and parents, not a categorical ban written by legislators. The European countries that tightened access mostly did so through their health systems, kept some access through research settings and specialist clinics, and did not criminalize doctors. A blanket ban removes the individual judgment that hard cases most need. And the costs of not treating some adolescents, including distress and self-harm, are real too.

Here's the argument I would make: whatever your view of the medicine, the constitutional question in Skrmetti was not whether the treatments are wise. It was who decides and how hard a court looks at the law. The Court chose to look lightly. That choice will matter for many laws that have nothing to do with medicine.

What the ruling left open

Skrmetti answered one question and pointedly left several others.

It did not decide whether transgender status is a protected class under equal protection. Three justices said it is not; the majority declined to say. It did not decide whether parents have a constitutional right to obtain this care for their children, because the Court did not take up that question. It did not decide whether Bostock's reasoning applies to the Constitution or to other statutes. It did not address adults, and laws affecting trans adults' care or coverage remain a separate battleground.

The Court has since decided related cases. In June 2026, in West Virginia v. B.P.J., it held that Title IX and the Equal Protection Clause allow states to maintain sex-based school sports teams. In Chiles v. Salazar, in March 2026, it held that Colorado's ban on conversion therapy, as applied to talk therapy, regulates speech by viewpoint. Read together, the recent cases give states broad room to regulate in this area, from more than one direction, and leave much of the fight to state legislatures, state courts and ballots.

What families are living with

Behind the doctrine are teenagers and parents. In states with bans, families have faced hard choices: stopping treatment, travelling to another state for care, or in some cases moving. Some doctors in states with bans have closed or limited their practices. In states without bans, clinics have reported more out-of-state patients. Some states have passed shield laws meant to protect providers and families from out-of-state legal action.

Those families are neighbours, coworkers and church members, and many of them live in conservative communities they love. The most effective advocacy in this area has often come from parents speaking to legislators as parents, not as activists. A conversation that starts with a child's name tends to go differently from one that starts with a slogan, on every side.

A case that changed sides in midstream

The procedural history of Skrmetti is unusual enough to deserve its own telling, because it shows how a change of administration can reach into the Supreme Court's courtroom.

The families who challenged Tennessee's law brought their own suit, represented by civil liberties lawyers, and the federal government under President Biden joined it. After the Sixth Circuit ruled for Tennessee, the families and the government each asked the Supreme Court to step in. The Court chose the government's petition, which presented the equal protection question alone. That choice is why the parents' rights claim never reached the justices.

The case was argued on December 4, 2024. Elizabeth Prelogar, then the Solicitor General, argued for the United States. Chase Strangio of the American Civil Liberties Union argued for the families, the first openly transgender lawyer to argue before the Court. The justices' questions that morning suggested where the majority was heading: several focused on the state of the medical evidence and on whether courts or legislatures should weigh it.

Then the government changed hands. In early 2025, after President Trump took office, the Justice Department informed the Court that it no longer agreed with the position its predecessors had taken, but it did not ask the Court to dismiss the case, and the families remained in it as parties. So a case captioned "United States" against a state ended up being decided with the United States no longer defending the side it had brought.

That episode is a small lesson in how much the executive branch shapes constitutional law. The government chooses which cases to bring and which to appeal, and which arguments to press or abandon. A new administration can drop appeals, settle suits and switch positions, and the Court must then decide whether the dispute is still worth hearing. Here the justices kept the case, in part because the private parties remained, and decided it anyway.

The broader point is about where power sits. Civil rights enforcement in the United States has always depended heavily on the federal government's willingness to sue, from school desegregation to voting rights to employment. When that willingness shifts, private lawyers and nonprofits carry more of the load, and the people they represent depend more on donations and volunteers. That is one reason the organizations doing this work matter so much, whoever is in the White House.

What you can do

Skrmetti moved much of this fight back to the states. That puts it within reach of ordinary citizens.

• Know your state legislators. Enter your address at find your representatives to see your state senator and representative, how to contact them and their recent votes. Bills on gender-affirming care, insurance coverage and shield laws are written at the state level.
• Follow the docket. Court watch shows this term's Supreme Court opinions with the Court's own summaries and its emergency docket, so you can see what is actually being decided.
• Find support for families. The organizations directory lists LGBTQ+, health and legal aid groups in every state; many run support networks for parents of trans kids.
• Stay informed beyond the headlines. The LGBTQ rights topic page and the courts topic page collect reporting on state bills and new rulings.
• Show up as a neighbour. If you are a parent, a teacher or a pastor, the most useful thing you may ever do on this issue is tell a lawmaker, face to face, about a real kid you know.