Transgender Treatment Bans and Equal Protection:
United States v. Skrmetti (2025) Sets the Rational-Basis Benchmark

Introduction

In United States v. Skrmetti, No. 23-477 (June 18 2025), the U.S. Supreme Court upheld Tennessee’s “Prohibition on Medical Procedures Performed on Minors Related to Sexual Identity” (SB 1). By a 5–4 vote the Court concluded that SB 1’s categorical ban on puberty blockers and cross-sex hormones for treating gender dysphoria in minors (a) neither employs a constitutionally suspect classification nor targets a fundamental right, and therefore (b) is subject only to rational-basis review, which it survives. The case is the Court’s first decision squarely addressing state restrictions on gender-affirming medical care for minors and markedly narrows the circumstances in which sex-related classifications trigger heightened judicial scrutiny.

Summary of the Judgment

Writing for the majority, Chief Justice Roberts (joined by Thomas, Gorsuch, Kavanaugh, and Barrett) held:

• SB 1 contains two facial classifications—age and medical purpose—which historically receive only rational-basis review.
• The law neither facially nor covertly classifies by sex: any minor, irrespective of sex, is barred from receiving the specified treatments for the disallowed diagnosis but may receive the same drugs for any other diagnosis (e.g. precocious puberty).
• Discrimination against transgender persons is not per se sex discrimination under the Equal Protection Clause; nor is transgender status a suspect or quasi-suspect class.
• Tennessee’s asserted interests—protecting minors from uncertain and potentially irreversible medical risk—are legitimate, and the statutory means are rationally related to those interests.

The Court affirmed the Sixth Circuit’s decision that vacated a district-court injunction, thereby allowing SB 1 to take effect statewide. Two concurring opinions (Thomas; Barrett joined by Thomas) and one opinion concurring in part (Alito) supplied additional reasoning. Justice Sotomayor, joined by Jackson (and in part by Kagan), filed a lengthy dissent; Justice Kagan wrote a separate dissent joining Parts I–IV of Justice Sotomayor’s opinion.

Analysis

A. Precedents Cited and Their Influence

• Geduldig v. Aiello, 417 U.S. 484 (1974)
  Used to analogize Tennessee’s exclusion of hormone therapy for gender dysphoria to California’s exclusion of pregnancy-related conditions from disability insurance. Footnote 20—often criticised—furnished the majority’s template for finding no sex classification where the statute removes one condition (here, gender dysphoria) from coverage.
• Nguyen v. INS, 533 U.S. 53 (2001)
  Cited for the proposition that mere reference to sex does not automatically trigger heightened scrutiny; what matters is whether the State is disadvantaging one sex because of sex-based stereotypes.
• United States v. Virginia (VMI)
  Sets out the exceedingly persuasive justification standard for sex classifications—relied on heavily by the dissent to argue that SB 1 required intermediate review.
• Bostock v. Clayton County, 590 U.S. 644 (2020)
  Majority distinguishes Bostock (a Title VII case) as text-specific and not controlling for constitutional analysis; dissent says the but-for logic of Bostock applies and makes sex dispositive.
• FCC v. Beach Communications, 508 U.S. 307 (1993)
  Provides the deferential rational-basis formulation—any reasonably conceivable state of facts—embraced by the majority.

B. The Court’s Legal Reasoning

1. Characterisation of the Classification
   • Tennessee’s two operative categories are (i) minors vs. adults (age); and (ii) medical purpose (diagnosis).
   • Because both categories historically receive rational-basis review, sex or transgender status must be present in fact before heightened scrutiny applies.
   • SB 1’s diagnosis-based rule applies identically to males and females; it merely excludes one set of diagnoses—gender dysphoria, gender identity disorder, and gender incongruence—regardless of whether the patient is male or female.
2. Rejection of Sex-based or Transgender-status Classification
   • Reference to sex is not enough; the law must differentiate between males and females.
   • Following Geduldig, transgender status is not equivalent to sex because not all transgender individuals seek the excluded treatments and some non-transgender minors may seek them for other indications.
   • The Court declines to recognise transgender persons as a suspect or quasi-suspect class and expressly reserves that broader question.
3. Application of Rational-Basis Review
   • Legitimate interests: safeguarding minors, addressing medical uncertainty, preventing regret, encouraging alternative therapies.
   • Rational connection: legislative findings cite sterility risk, bone-density concerns, European policy shifts, and evidence of detransition; under Beach Communications, such conjectures suffice.

C. Likely Impact of the Decision

• Green Light for State Legislatures. States may impose sweeping restrictions on gender-affirming medical care for minors without fear of intermediate scrutiny. Over two-thirds of States have introduced or enacted similar bills; litigation in Alabama, Arkansas, Florida, Indiana, Kentucky, Missouri, Oklahoma, Texas, and West Virginia is immediately affected.
• Narrowing of Sex-based Equal Protection. The decision signals that statutory language can avoid heightened scrutiny if it is framed as an age or diagnostic distinction, even when the real-world effect falls almost exclusively on one sex or on transgender persons. Lower courts may now re-evaluate other laws—bathroom bills, athletic participation rules, dress codes—under rational-basis review.
• Doctrinal Tension with Title VII and Title IX. By refusing to extend Bostock’s reasoning, the Court creates a sharper divergence between employment-discrimination jurisprudence (statutory) and equal-protection doctrine (constitutional). Litigants may argue that sex-identity claims fail under the Constitution even if they succeed under federal statutes.
• Future of Suspect-Class Analysis. The concurring opinions by Justices Barrett and Alito criticize the Court’s willingness to create any new suspect classes, raising the bar for recognition of transgender status—or any emerging category—as warranting heightened scrutiny.

Complex Concepts Simplified

Equal Protection Clause

Part of the 14^th Amendment requiring states to treat people alike unless there is a sufficiently good reason to distinguish.

Levels of Scrutiny

• Strict scrutiny: State must show law is narrowly tailored to a compelling interest (applies to race, national origin, religion).
• Intermediate scrutiny: Law must be substantially related to an important interest (applies to sex in most settings).
• Rational-basis review: Law upheld if any conceivable legitimate interest could support it (default rule).

Gender-Affirming Medical Care

Medical interventions—puberty blockers, hormone therapy, sometimes surgery—provided to align a person’s physical traits with their gender identity.

Transgender Status

A condition in which a person’s gender identity (internal sense of being male, female, or another gender) differs from the sex assigned at birth.

Puberty Blockers vs Hormone Therapy

Puberty blockers pause pubertal development; hormone therapy initiates or promotes secondary sex characteristics (e.g. facial hair, breast development). Both can be used for various conditions (precocious puberty, delayed puberty, gender dysphoria).

Conclusion

United States v. Skrmetti is a watershed in equal-protection doctrine. By holding that blanket bans on gender-affirming medical care for minors merit only rational-basis review, the Court re-positions sex-based analysis, fortifies state autonomy over a newly contested medical domain, and starkly diverges from its own statutory antidiscrimination jurisprudence. The decision leaves open whether transgender status can ever be a protected class, but its reasoning and concurring opinions suggest an uphill battle. In the near term, the ruling invites further legislation restricting transgender healthcare and signals a more deferential era when sex-related classifications are framed in “age-and-use” terms. The ultimate impact—on constitutional law, on state policymaking, and most acutely on transgender adolescents and their families—will unfold in the coming years, but Skrmetti has undeniably set a new precedent that will guide (and constrain) that future.