United States v. Skrmetti

Facts of the Case

Provided by Oyez

In 2023, Tennessee and Kentucky passed laws restricting certain medical treatments for transgender minors. These laws prohibited healthcare providers from administering puberty blockers, hormone therapy, and sex-transition surgeries to minors for the purpose of altering their appearance or validating their gender identity when inconsistent with their biological sex. Both laws included exceptions for certain medical conditions and provided mechanisms for enforcement, including professional discipline for healthcare providers and extended statutes of limitations for lawsuits.

In response, groups of transgender minors, their parents, and healthcare providers challenged these laws in federal court. The plaintiffs argued that the laws violated their constitutional rights to due process and equal protection. They sought preliminary injunctions to prevent the laws from taking effect. In both cases, district courts initially granted injunctions, finding that the laws likely infringed on parents’ fundamental rights to direct their children's medical care and discriminated based on sex. The U.S. Court of Appeals for the Sixth Circuit stayed these injunctions, allowing the laws to go into effect pending further legal proceedings.

Questions

Does a Tennessee law restricting certain medical treatments for transgender minors violate the Equal Protection Clause of the 14th Amendment?

Conclusions

Tennessee’s law prohibiting certain medical treatments for transgender minors is not subject to heightened scrutiny under the Equal Protection Clause of the Fourteenth Amendment and satisfies rational basis review. Chief Justice John Roberts authored the 6-3 majority opinion of the Court.

First, the Equal Protection Clause does not require heightened scrutiny because Tennessee’s law does not classify on any bases that warrant such review. The law contains only two classifications: one based on age (allowing treatments for adults but not minors) and another based on medical use (permitting puberty blockers and hormones for certain conditions but not for treating gender dysphoria). Classifications based on age or medical use receive only rational basis review—the most deferential standard of constitutional review. The law does not classify based on sex because it prohibits healthcare providers from administering these treatments to any minor for the excluded diagnoses, regardless of the minor's biological sex. When properly understood as regulating specific combinations of drugs and medical indications, the law treats all minors equally: none may receive these treatments for gender dysphoria, but minors of any sex may receive them for other qualifying conditions like precocious puberty or congenital defects.

The law satisfies rational basis review because Tennessee’s legislature had reasonable grounds for its restrictions. The state found that these treatments for gender dysphoria carry risks including irreversible sterility, increased disease risk, and adverse psychological consequences, while minors lack the maturity to understand these consequences and many express later regret. Tennessee also determined that the treatments are experimental with unknown long-term effects, and that gender dysphoria can often be resolved through less invasive approaches. Under rational basis review, courts must uphold laws if there are any reasonably conceivable facts supporting the classification. States have wide discretion in areas of medical and scientific uncertainty, noting that recent reports from health authorities in England and other countries have raised similar concerns about the evidence supporting these treatments for minors.

Justice Clarence Thomas authored a concurring opinion, joined by Justice Amy Coney Barrett, arguing that Bostock v. Clayton County (in which the Court held that Title VII of the Civil Rights Act’s prohibition on discrimination because of sex includes discrimination based on transgender identity or sexual orientation) should not apply to Equal Protection Clause analysis and criticizing deference to medical experts who lack consensus and have allowed political ideology to influence their guidance on transgender treatments for minors.

Justice Barrett authored a concurring opinion, joined by Justice Thomas, arguing that transgender individuals do not constitute a suspect class under the Equal Protection Clause because they lack the “obvious, immutable, or distinguishing characteristics” of a “discrete group” and because suspect class analysis should focus on a history of de jure (legal) discrimination rather than private discrimination.

Justice Samuel Alito authored an opinion concurring in part and concurring in the judgment, arguing that while Tennessee’s law does not classify based on sex, it may classify based on transgender status. However, he argued, transgender individuals do not constitute a suspect or quasi-suspect class warranting heightened scrutiny because they lack the immutable characteristics, history of pervasive legal discrimination, and political powerlessness that define such classes.

Justice Sonia Sotomayor authored a dissenting opinion, joined by Justice Ketanji Brown Jackson in full and by Justice Elena Kagan in part, arguing that Tennessee's law plainly classifies on the basis of sex because it conditions access to medical treatments on whether they are "inconsistent with" a minor's sex, and therefore should be subject to intermediate scrutiny rather than the rational basis review applied by the majority. Justice Kagan wrote separately to clarify that she takes no view on how the Tennessee law would fare under heightened scrutiny.