Supreme Court Skrmetti Decision Permits Ban on Gender-Affirming Care for Children

How Supreme Court Trans Health Care Ruling Will Affect Kids

By Allison Parshall edited by Dean Visser

The U.S. Supreme Court has upheld a Tennessee law banning gender-affirming care for minors in the case US v. Skrmetti. In a 6–3 decision by the conservative supermajority, the court ruled that the state law, called Senate Bill 1 (SB1), does not violate the Equal Protection Clause of the Constitution by discriminating on the basis of sex—despite the fact that the law forbids certain medical treatments for young people based on their assigned sex at birth.

Why This Matters

The ruling is a major blow to transgender Americans’ rights and protections, which have been under attack at the state and federal level. The challenge to Tennessee’s SB1 had been brought by three transgender adolescents, their families and a doctor. “This might seem like a small issue to others but it affects my whole world,” wrote one of the plaintiffs, a then 12-year-old transgender boy, in a declaration submitted to the district court. “I’ve gone through a lot to finally get to the happy, healthy place where I am and I desperately hope that doesn’t all get taken away from me.”

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For anyone under the age of 18, SB1 banned medical treatments that aim to alleviate the symptoms of gender dysphoria—a feeling of misalignment between someone’s perceived gender and their assigned sex at birth. The law bans gender-affirming medical treatments, including puberty-blocking drugs and hormone therapies. There’s no evidence of serious negative effects of these medications, though long-term use of puberty blockers may limit the buildup of bone mineral density.

Such medications have also long been used by nontransgender adolescents and children to treat a variety of conditions. Their use for gender dysphoria is currently supported by the American Medical Association, the American Association of Pediatrics, the American Psychological Association and other important medical institutions.

Research has shown that young people who experience gender dysphoria are at a high risk of depression and suicide. Those who receive care have better mental health outcomes, including decreased suicidal ideation, multiple studies have found. In contrast, between 2018 and 2022, when states enacted antitransgender laws, suicide attempts among transgender young people increased by as much as 72 percent. In the U.K., a ban on puberty blockers for transgender youth led to a sharp decline in mental health among this group, including increased depression, social isolation, and suicidal ideation, a recent study found.

The Decision

In the Supreme Court’s majority decision, Chief Justice John Roberts pointed to “fierce scientific and policy debates about the safety, efficacy, and propriety” of the treatments. Many of those debates have largely been political, not scientific, however.

The Court was tasked with deciding whether the law constituted sex discrimination under the Equal Protection Clause and should thus be subject to a higher level of judicial scrutiny. Plaintiffs argued that SB1 prohibits established medical treatments for some people and allows them for others based on individuals’ assigned sex at birth. For example, in Tennessee, a teenager who had been assigned female at birth could not receive testosterone therapy, but a teenager who had been assigned male at birth could.

“The Equal Protection Clause does not resolve these disagreements,” Roberts wrote in the majority opinion. “Nor does it afford us license to decide them as we see best. Our role is not ‘to judge the wisdom, fairness, or logic’ of the law before us … but only to ensure that it does not violate the equal protection guarantee of the Fourteenth Amendment. Having concluded it does not, we leave questions regarding its policy to the people, their elected representatives, and the democratic process.”

In dissent, Justice Sonia Sotomayor wrote, “Tennessee’s law expressly classifies on the basis of sex and transgender status…. The majority contorts logic and precedent to say otherwise, inexplicably declaring it must uphold Tennessee’s categorical ban on lifesaving medical treatment…. By retreating from meaningful judicial review exactly where it matters most, the Court abandons transgender children and their families to political whims. In sadness, I dissent.”

What the Experts Say

The Court’s decision means that Tennessee’s SB1 and any similar state laws do not merit heightened scrutiny from the judicial system to ensure they are appropriate. “This is unfortunate because the evidence base regarding gender-affirming care is overwhelming supportive of access to the care,” says Elana Redfield, a LGBTQ+ policy expert at the Williams Institute at the University of California, Los Angeles. “However, the legislature disregarded this evidence and relied instead on misinformation and conjecture when it passed the law—and, one can argue, bias against transgender people.”

Redfield notes that the case’s outcome doesn’t prevent states from passing laws to protect access to gender-affirming care—as 14 states and Washington, D. C., have chosen to do. She adds that the ruling also does not prevent future challenges to antitransgender laws from being brought before the Court on different grounds.

Lawrence Gostin, co-faculty director of the O’Neill Institute for National and Global Health Law at Georgetown University Law Center, has decried the Court’s decision. “It’s jaw-dropping to see a majority of Supreme Court justices turn a blind eye while transgender minors are flatly denied access to health services in consultation with their doctors,” Gostin said in a recent press release. “The Court is greenlighting red state laws that will deeply affect the lives of marginalized and victimized people seeking healthcare, social acceptance, and dignity. This decision paves the way for additional restrictions on other essential but politically fraught services, notably within sexual and reproductive health.”

Read More about the Case and Transgender-Affirming Care

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