The Supreme Court of the United States recently confirmed the legality of a Tennessee statute that prohibits gender-affirming medical treatments for minors, in the case U.S. v. Skrmetti. The decision, which came down 6–3 from the court’s conservative majority, concluded that Senate Bill 1 (SB1) does not contravene the Constitution’s Equal Protection Clause by discriminating based on sex, although the law restricts certain medical procedures for minors according to their sex at birth.

The Significance of the Ruling

This verdict represents a significant setback for the rights and protections of transgender individuals in America, which have faced challenges both at the state and national levels. The legal opposition to Tennessee’s SB1 was initiated by three transgender teenagers, their families, and a physician. “This issue might appear minor to some, but it encompasses my entire life,” stated a 12-year-old transgender boy, one of the plaintiffs, in a sworn statement to the district court. “I have struggled greatly to reach the content, healthy state I am in now, and I am terrified of losing that.”

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SB1 explicitly forbids any medical intervention designed to treat symptoms of gender dysphoria—where one’s experienced gender does not align with their biological sex assigned at birth—for individuals below 18 years. This includes puberty blockers and hormone treatments, despite the lack of evidence indicating severe adverse effects from these drugs. However, prolonged use of puberty blockers has been associated with potential impacts on bone mineral density.

These medications have also been prescribed to cisgender youths for various other medical conditions and are currently endorsed by major medical bodies such as the American Medical Association, the American Association of Pediatrics, and the American Psychological Association.

Studies indicate that transgender youths experiencing gender dysphoria are at an elevated risk of depression and suicide. Access to gender-affirming care has been linked to improved mental health outcomes and a reduction in suicidal thoughts, according to multiple research findings. Conversely, the introduction of anti-transgender legislation between 2018 and 2022 led to a surge in suicide attempts among transgender youths by up to 72 percent. Furthermore, a study in the UK showed that prohibiting puberty blockers for transgender minors significantly worsened their mental health, increasing feelings of depression, social isolation, and suicidal thoughts.

Ruling Overview

Chief Justice John Roberts, in the majority opinion, referenced “intense debates over the safety, effectiveness, and appropriateness” of these treatments, noting that these discussions are often more political than scientific. The court was tasked with determining whether the law constituted sex discrimination under the Equal Protection Clause, thus requiring more stringent judicial scrutiny. Plaintiffs argued that SB1 selectively prohibits established medical treatments based on the sex assigned at birth; for instance, a Tennessee teen assigned female at birth could not receive testosterone therapy, unlike their male-assigned counterparts.

“The Equal Protection Clause does not settle these debates,” wrote Roberts. “It does not permit us to decide based on what we believe is right… Our duty is not to evaluate the law’s wisdom, fairness, or logic… but merely to ensure it does not breach the Fourteenth Amendment’s guarantee of equal protection. Having determined that it does not, we leave policy judgments to the public, their representatives, and the democratic process.”

In her dissent, Justice Sonia Sotomayor argued, “Tennessee’s statute explicitly discriminates based on sex and transgender status… The majority’s decision to uphold this outright ban on critical medical care is baffling and departs from established judicial standards… By pulling back from rigorous judicial scrutiny where it is most needed, the Court forsakes transgender minors and their families to the fickleness of politics. With regret, I dissent.”

Expert Opinions

According to the Court’s ruling, Tennessee’s SB1 and similar laws in other states will not undergo rigorous judicial scrutiny to verify their validity. “It’s regrettable because the scientific support for gender-affirming care is overwhelmingly in favor of access to such treatments,” stated Elana Redfield, an LGBTQ+ policy specialist at the Williams Institute at UCLA. “Yet, the lawmakers chose to ignore this evidence, opting instead for misinformation and bias against transgender individuals when enacting this legislation,” she added.

Redfield also mentioned that the ruling does not prevent states from enacting laws to safeguard access to gender-affirming care, as already done by 14 states and Washington, D.C. It also does not stop future legal challenges against anti-transgender laws on different grounds.

Lawrence Gostin, co-director of the O’Neill Institute for National and Global Health Law at Georgetown University, criticized the decision. “It’s astonishing to witness a majority of the Supreme Court justices disregard the denial of necessary health services to transgender minors in consultation with their doctors,” he expressed in a recent statement. “The decision endorses conservative state laws that will significantly impact the lives of marginalized and vulnerable individuals seeking healthcare, social acceptance, and dignity. This sets a precedent for further restrictions on other critical but politically sensitive services, notably in sexual and reproductive health.”

Further Reading on the Case and Transgender-Affirming Care

• Last December, Scientific American interviewed health policy experts about the implications of the U.S. v. Skrmetti case.

• A study in January involving 315 transgender youths showed improved emotional well-being following hormone therapy.

• Discover more about “What Are Puberty Blockers, and How Do They Work?”

• Learn about “What the Science Says on Gender-Affirming Care for Transgender Kids.”

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