The U.S. Supreme Court upholds Tennessee’s ban on gender-affirming care for minors in a 6-3 ruling. A decision with wide-reaching implications for transgender rights and state healthcare regulation.

Written By EEW Magazine Online Editorial Team

In a landmark decision with broad implications for transgender rights and state-level healthcare regulation, the U.S. Supreme Court on Tuesday upheld a Tennessee law prohibiting gender-affirming medical care for minors.

The 6–3 ruling in United States v. Skrmetti affirms the state’s authority to restrict treatments such as puberty blockers and hormone therapy for youth seeking to transition.

Chief Justice John Roberts authored the majority opinion, stating that the law does not violate the Equal Protection Clause of the 14th Amendment. The decision emphasized the role of elected officials in resolving policy debates involving complex medical and ethical questions.

The voices in these debates raise sincere concerns; the implications for all are profound,” Roberts wrote. “Nothing in the Constitution prevents state legislatures from adopting laws that restrict certain medical treatments for minors.”

The ruling upholds Tennessee’s Senate Bill 1 (SB 1), enacted in 2023, which bars healthcare providers from administering gender-affirming hormone treatments and puberty blockers to individuals under 18. The law also permits civil penalties and professional disciplinary actions against those who violate the statute. Surgical procedures were not at issue in the case.

The challenge to SB 1 was brought by three families of transgender minors and a physician providing gender-affirming care, later joined by the Biden administration. Plaintiffs argued the law discriminates based on sex and gender identity, noting that medications permitted for cisgender youth—for example, testosterone for delayed puberty—are banned when used by transgender youth to treat gender dysphoria.

Tennessee defended the law as a necessary safeguard for minors, citing concerns over what it characterized as “experimental” treatments. The state argued the law applies neutrally, restricting care based on age and medical purpose rather than sex. Tennessee also pointed to recent developments abroad, including England’s decision to limit access to puberty blockers to clinical trials following the Cass Review, which raised concerns about long-term outcomes.

The court’s conservative majority concluded that SB 1 does not trigger heightened judicial scrutiny and should be reviewed under the rational basis standard—the most deferential level of constitutional review. That framework makes it more likely similar laws will survive legal challenges in other jurisdictions.

In a sharply worded dissent, Justice Sonia Sotomayor, joined by Justices Elena Kagan and Ketanji Brown Jackson, accused the court of abdicating its duty to protect a vulnerable minority.

“By retreating from meaningful judicial review exactly where it matters most, the court abandons transgender children and their families to political whims,” Sotomayor wrote. “In sadness, I dissent.”

She referenced the court’s 2020 ruling in Bostock v. Clayton County, which held that employment discrimination based on sexual orientation or gender identity violates Title VII of the Civil Rights Act. The dissent argued that the logic in Bostock should apply more broadly to equal protection cases involving transgender individuals.

The decision is the court’s most significant ruling on transgender rights since Bostock, and it comes amid a surge in legislation focused on LGBTQ+ youth. As of March 2023, 30 states have restricted access to gender-affirming care or are currently considering laws that would do so, according to data from the Williams Institute at UCLA School of Law. Additional laws in many of those states restrict transgender students from participating on sports teams aligned with their gender identity.

The ruling is expected to influence the outcome of similar legal challenges across the country, reinforcing the legal foundation for state-level bans. However, the opinion does not address broader constitutional issues, including parental rights under the 14th Amendment—a question likely to surface in future litigation.

Medical organizations, including the American Academy of Pediatrics and the American Psychological Association, have endorsed gender-affirming care as evidence-based and medically necessary. They oppose state bans, citing research showing such treatments can reduce depression and suicidality in youth experiencing gender dysphoria.

On the other side of the debate, advocates of bans have leaned on European models for justification. The Cass Review in the U.K., which found insufficient evidence to support widespread use of puberty blockers in young people, has been frequently cited by conservative lawmakers seeking tighter restrictions.

Mental health advocates warn that such policies carry significant risks. A 2023 study from The Trevor Project, a pro LGBTQ+ organization, found that transgender and nonbinary youth exposed to anti-trans legislation reported a 72% higher rate of suicide attempts.

The political backdrop to the ruling is also significant. During the litigation, the Trump administration, following his 2024 reelection, withdrew federal opposition to the Tennessee law. President Trump also signed an executive order restricting gender-affirming care—a measure that was later blocked by a federal judge—and reinstated limitations on transgender military service.

With its decision in United States v. Skrmetti, the Supreme Court has effectively signaled judicial deference to states on the issue of transgender healthcare policy, while leaving open constitutional questions that may resurface in future cases. For now, Tennessee’s law stands—and with it, a roadmap for other states seeking to follow suit.

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