United States v. Skrmetti, 605 U.S. 495 (2025), is a United States Supreme Court case which held that a Tennessee state law banning puberty blockers and hormone therapy for the treatment of gender dysphoria in minors did not violate the Equal Protection Clause of the Fourteenth Amendment to the United States Constitution.
Under Tennessee’s law, a child could receive puberty blockers and hormone therapy if the medications were provided to help them conform to their sex assigned at birth, but not to treat gender dysphoria. The plaintiffs argued this constituted sex-based discrimination and thus violated the Equal Protection Clause. Tennessee argued the law did not treat people differently based on their sex, but rather based on their age and medical condition.
The district court applied heightened scrutiny and blocked the law from taking effect. The Court of Appeals for the Sixth Circuit overturned, ruling the ban did not discriminate based on sex and thus only required rational basis review.
The Supreme Court upheld the appellate court's decision on a 6–3 split, with the six conservative justices agreeing the ban was based on age and medical reason for treatment rather than on sex. Writing for the majority, Chief Justice John Roberts emphasized that the ruling was not based on an ideological opposition to transgender rights; writing for the minority, Associate Justice Sonia Sotomayor criticized the Court's decision as a failure to uphold the civil rights of transgender youth.
Background
Since 2020, many states with Republican-led legislatures introduced bathroom bills and bills to limit transgender schoolchildren from participating in sports corresponding to their gender identity, and while many were defeated or challenged legally, there was public support for these bills in those states, leading the Republicans further their efforts to limit transgender rights as part of their platform as to draw in support from religious groups.
Major medical associations in the United States had opposed these bans at the time. In June 2023 the Endocrine Society released a statement opposing such bans whose signatories included the American Academy of Pediatrics, American College of Obstetricians and Gynecologists, American Urological Association, American Society for Reproductive Medicine, American College of Physicians, American Association of Clinical Endocrinology, and the American Medical Association (AMA).
On March 22, 2023, the Tennessee House of Representatives passed HB1 amending the Tennessee Code prohibiting surgical procedures and hormone therapies for transgender minors with a diagnosis of gender dysphoria. This includes puberty blockers, hormone therapy, and surgeries (though the ban on the latter was not at issue in the case). The bill does not restrain the use of puberty blockers and hormones for other medical purposes such as the treatment of precocious puberty. As of December 2024, 23 other states had similar laws in place which could be affected by the Supreme Court's decision in this case (see List of legislation restricting transgender youth health care in the United States).
Upon passage of the law, the Biden Department of Justice sought an injunction in the US District Court for the Middle District of Tennessee to prevent the law from going into effect on July 1, 2023.
The District Court granted a preliminary injunction, preventing the ban on hormones and puberty blockers from going into effect, but did not issue a ruling regarding the ban on gender-affirming surgery. The court deemed the state ban on the former two as infringing on the "fundamental rights" of parents.
Plaintiffs The suit was brought by three transgender teens and their families as well as a Tennessee doctor who treats youth with gender dysphoria. The Biden administration joined the plaintiffs under a law which allows the federal government to join in private suits which allege violations of the Equal Protection Clause. Among the plaintiffs is a 16-year old transgender girl, identified only as "L.W.", and her parents, Brian and Samantha Williams, of Nashville, Tennessee. L.W. is a recipient of gender-affirming hormone therapy, which she says has greatly improved her quality of life, describing the gender dysphoria she experienced before treatment as "real-life body horror", and saying that her treatment allows her to "feel normal". The Tennessee state ban forces the Williams family to travel out-of-state for L.W.'s hormone treatments. Biden administration Solicitor General Elizabeth Prelogar advocated for the plaintiff's right to "be a girl" in Tennessee. Samantha Williams accused Tennessee lawmakers of hypocrisy, as they had championed "parental rights" with regard to COVID-19, but sought to restrict parental rights via HB1, saying, "They made this medical decision for our child."
The Biden administration argued in favor of the plaintiffs before the Supreme Court in December 2024. After President Donald Trump was inaugurated in January 2025, the Trump administration informed the Supreme Court on February 7, 2025, that it had changed the United States' stance and no longer supported the plaintiffs. The Trump administration nonetheless urged the justices to issue a decision on the case.
Sixth Circuit The District Court's ruling was appealed to the US Court of Appeals for the Sixth Circuit. In a 2–1 decision in July 2023, the Sixth Circuit stayed the lower court's decision to grant a preliminary injunction, applying rational basis review. Chief Judge Jeffrey Sutton wrote that the Tennessee state government was likely to succeed upon their appeal and that the right of parents to control the medical care of their children is not a fundamental right because it is not "deeply rooted in this Nation's history and tradition", a standard set by the Supreme Court in Washington v. Glucksberg (1997). Judge Helene White concurred in part and dissented in part, arguing that the Tennessee law is "likely unconstitutional based on the Plaintiffs’ theory of sex discrimination" and that she would not stay the injunction but rather narrow its scope. However, she agreed that the "District Court abused its discretion in granting a statewide preliminary injunction".
By a 2–1 vote in September 2023, the Sixth Circuit panel reversed the district court's preliminary injunction, with Sutton again writing for the majority and White again dissenting.
Legal analysis The plaintiffs advanced two lines of argument by which Tennessee's HB1 violates the Equal Protection Clause of the Fourteenth Amendment: that it discriminates by sex, and that it discriminates by transgender status, which they contend is a "suspect" (or "quasi-suspect") class. Either of these forms of discrimination would trigger a heightened scrutiny standard of review which the law would not survive, according to the plaintiffs' arguments. Gender discrimination has a lower standard of review than racial discrimination: namely, intermediate scrutiny since Craig v. Boren (1976).
A separate due process argument was raised before the lower courts but the Supreme Court declined to consider it.
Sex discrimination The plaintiffs argued that the Tennessee law engages in facial sex discrimination. Because the law allows the use of puberty blockers and hormones for reasons unrelated to transition, they argued, a patient's sex becomes a determining factor in deciding whether these treatments are permissible. For example, a male adolescent would be permitted to take testosterone as a treatment for delayed puberty, but the same medication would be disallowed for a patient whose birth sex is female (taking it for the purposes of inducing physical changes consistent with a masculine or nonbinary gender identity). The government and families also pointed to the Supreme Court's decision in Bostock v. Clayton County (2020), which upheld that both sexual orientation and gender identity are necessarily covered by the Title VII of the Civil Rights Act of 1964's bar on sex discrimination.
Tennessee denied that the law draws classifications based on sex, arguing that it instead draws a distinction according to the purposes for which a treatment is given, distinguishing between "minors seeking drugs for gender transition and minors seeking drugs for other medical purposes".
Discrimination on transgender status The plaintiffs further argued that the bill warrants heightened scrutiny because it discriminates against transgender individuals who, they argued, constitute at least a quasi-suspect class. In identifying whether a group constitutes a suspect or quasi-suspect class, the plaintiffs stated that the courts should look to four criteria: The group has historically been discriminated against or have been subject to prejudice, hostility, or stigma. They possess an immutable or highly visible trait. They lack political power. The group's distinguishing characteristic does not inhibit it from contributing meaningfully to society. The plaintiffs argued that transgender people as a group met all four criteria.
Tennessee denied that the bill discriminates on transgender status, arguing again that it distinguishes only different medical uses, and pointing out that, for example, a transgender youth would be permitted to use puberty blockers for purposes unrelated to gender transition (such as to treat precocious puberty). The state further argued that even if the bill were considered to discriminate on transgender status, the court should not "get back in the fraught business of creating suspect classes".
Legal experts considered it very unlikely that the court would accept the plaintiffs' argument in identifying transgender people as a quasi-suspect class, given that it had been decades since the court identified a new class as suspect or even quasi-suspect.
Supreme Court On November 6, 2023, the United States petitioned the Supreme Court to hear this case on appeal. The Supreme Court granted certiorari on June 24, 2024. Whereas the government's petition alleged a violation of the Equal Protection Clause, the plaintiffs filed a separate petition for certiorari, which the court did not grant, which additionally presented the theory that the bill violated the Due Process Clause by denying parents the right to make medical decisions for their children.
On February 7, 2025, the Department of Justice under the Trump Administration reversed its previous stance under the Biden Administration, claiming in a letter to the Supreme Court that the Tennessee law does not violate equal protection based on sex or any other characteristic, but maintained that the Court should still proceed with ruling on the case. Prior to the letter's issuance, legal experts predicted that with oral arguments having already taken place, such a reversal would have little impact on the case.
Amicus briefs Amicus briefs filed for the petitioners, arguing against the ban, were submitted by the American Psychological Association, the American Academy of Pediatrics, the American Medical Association, and the World Professional Association of Transgender Health (WPATH), among other medical organizations. The Endocrine Society filed a brief stating the ban "irreparably harms adolescents with gender dysphoria by denying crucial care to those who need it".
Briefs supporting the respondents in favor of the ban included the State of Kentucky with 21 other states, the Alliance Defending Freedom, and the Family Research Council, among others.