United States v. Skrmetti

What happened

The question before the Court

The Court's answer

Curious how the Court got there? See the step-by-step legal reasoning →

Why it matters

What changes now

What this does not decide

Concurrence — Justice Thomas

Justice Thomas agreed with the majority but wrote separately on two points. First, he argued that Bostock's reasoning — based on Title VII's specific statutory text — should never be imported into Equal Protection Clause analysis, which uses entirely different language. Second, he urged deep skepticism toward claimed medical consensus in this area, detailing evidence that leading organizations like WPATH have allowed politics to shape their medical conclusions, suppressed unfavorable research, and tailored guidance to litigation strategy. Courts, he argued, should defer to legislatures, not experts.

Concurrence — Justice Barrett

Justice Barrett wrote separately to explain why, in her view, transgender people do not constitute a suspect class warranting heightened constitutional scrutiny. She reasoned that transgender status lacks the obvious, immutable, discrete characteristics that define recognized suspect classes like race or sex. She also argued that the history-of-discrimination factor should require a demonstrated pattern of formal legal discrimination — not merely private animus — and that creating a transgender suspect class would draw courts into a wide range of contested policy judgments about healthcare, sports, and other areas better left to legislatures.

Concurrence in part — Justice Alito

Justice Alito joined Parts I and II-B of the majority but not Parts II-A-2 and II-A-3. He agreed SB1 does not classify on the basis of sex, using his own analysis grounded in the original meaning of 'sex' in equal protection precedents as biological maleness or femaleness. He disagreed with the majority's conclusion that SB1 doesn't classify based on transgender status — acknowledging a strong argument that it does — but he would assume it classifies that way and still uphold the law because transgender status, in his view, does not qualify as a suspect or quasi-suspect class. He also refused to join the majority's Bostock analysis, arguing Bostock's methodology has no place in constitutional equal-protection cases.

Dissent — Justice Sotomayor

“By retreating from meaningful judicial review exactly where it matters most, the Court abandons transgender children and their families to political whims.”Justice Sotomayor's core objection to the majority's decision to apply the most permissive constitutional standard to a law she viewed as plainly sex-based.

Justice Sotomayor argued that SB1 plainly classifies on the basis of sex because whether a minor may receive puberty blockers or hormones turns entirely on whether the treatment is consistent or inconsistent with the minor's biological sex — males may get drugs that help them look like boys, females may get drugs that help them look like girls, but not the reverse. She argued this alone requires intermediate scrutiny. She also argued that transgender people bear the hallmarks of a quasi-suspect class, have suffered a long history of legal and private discrimination, and that the majority's refusal to apply meaningful review abandons transgender children to political whims.

Dissent — Justice Kagan

Justice Kagan agreed with Justice Sotomayor that intermediate scrutiny applies to SB1 and joined Parts I through IV of her dissent. She wrote separately to clarify that she takes no view on whether SB1 would actually survive intermediate scrutiny — a question she believes the lower courts should answer first on a full record. She would simply remand with instructions to apply the correct constitutional standard.

The legal reasoning, step by step

1. 1The Equal Protection Clause requires courts to choose the right level of review before deciding if a law is constitutional. Laws touching race or national origin get strict scrutiny — the hardest test. Laws classifying based on sex get intermediate scrutiny, requiring the State to show the classification serves an important goal and is closely tied to achieving it. Laws that don't invoke any of those special categories need only be rationally related to some legitimate government interest — a far easier standard to meet.
2. 2On whether SB1 classifies based on sex: the majority identified only two explicit classifications in the law — one based on age (adults may receive these treatments, minors may not) and one based on medical purpose (the drugs may be used for certain conditions but not for gender dysphoria or related diagnoses). Neither line is drawn between males and females. Under SB1, no minor of any sex may receive puberty blockers or hormones to treat gender dysphoria; minors of any sex may receive them for other purposes. The Court rejected the argument that the law's repeated references to sex, on their own, are enough to trigger heightened review.
3. 3The majority defined 'medical treatment' as encompassing both a drug and the specific condition it is prescribed to treat — so prescribing testosterone for a male-pattern hair condition is a different treatment than prescribing testosterone for gender dysphoria, even if the same drug is involved. Under this framing, SB1 restricts treatments defined by their medical purpose, not by a patient's sex. Changing the patient's sex in a hypothetical doesn't change SB1's outcome because the diagnosis — not the sex — is what determines whether the treatment is allowed.
4. 4On transgender-status discrimination: drawing on Geduldig v. Aiello (a 1974 case holding that excluding pregnancy from a disability insurance program did not discriminate against women as a class, even though only women can become pregnant), the majority reasoned that SB1 removes certain diagnoses from the list of treatable conditions rather than excluding transgender individuals as a class. Because both transgender and non-transgender minors fall into the group of minors who can receive puberty blockers for permitted purposes, the Court found no classification based on transgender status.
5. 5On whether Bostock v. Clayton County (2020) — which held that firing someone for being transgender is sex discrimination under federal employment law — required a different result: the majority applied Bostock's 'but-for cause' logic and found it pointed the other way. If a transgender boy's biological sex is changed from female to male in the thought experiment, he still could not receive testosterone for gender dysphoria under SB1 because he would still lack a qualifying diagnosis. The restriction turns on diagnosis, not sex — so sex is not the but-for cause of SB1's operation. The Court expressly declined to decide whether Bostock's reasoning extends to constitutional equal-protection claims.
6. 6Since no heightened scrutiny applied, the Court only asked whether SB1's age- and diagnosis-based restrictions were rationally related to a legitimate government interest. Tennessee's legislative findings — that administering these drugs to treat gender dysphoria in minors carries unknown long-term risks, may cause irreversible sterility, and that minors may lack the maturity to appreciate the full consequences — easily cleared rational basis review, a standard that merely requires some plausible reason for the classification. The Court noted ongoing international debates and recent restrictions by health authorities in England, Sweden, and Finland as further evidence of scientific uncertainty justifying legislative flexibility.

Laws and provisions at issue

Cases affected by this decision