A decision about scrutiny

On June 18, 2025, the Supreme Court decided United States v. Skrmetti by a 6-3 vote, upholding Tennessee’s law barring puberty blockers and hormone therapy for minors seeking treatment for gender dysphoria (slip opinion). The ruling left roughly 25 states’ bans on gender-affirming care for minors in effect (KFF).

The case is widely described as a decision about transgender health care. It is more precisely a decision about a narrow and technical question of constitutional law: what level of judicial scrutiny applies when someone challenges a law under the Equal Protection Clause. That question sounds procedural. It is in fact almost always decisive. Understanding why is the key to understanding both what Skrmetti did and what it deliberately left undone.

The equal-protection mechanism

The Fourteenth Amendment guarantees “the equal protection of the laws.” Every law classifies — it treats some people or activities differently from others — so the clause cannot mean that no classification is ever permitted. Instead, over the past century, courts have built a tiered framework. The tier a court selects largely determines the outcome.

• Rational-basis review is the default. The law need only be rationally related to some legitimate government interest. Courts will hypothesize justifications on the government’s behalf, and the challenger loses if “any reasonably conceivable state of facts” could support the classification. Laws almost always survive this tier.
• Intermediate (heightened) scrutiny applies to classifications based on sex. The government must show the law serves an “important” objective and is “substantially related” to it. This is a real test; many sex-based laws fail it.
• Strict scrutiny applies to classifications based on race or that burden fundamental rights. The law must be “narrowly tailored” to a “compelling” interest. Few laws survive.

The plaintiffs in Skrmetti — transgender minors, their parents, and a physician, joined by the United States under the Biden administration — argued that Tennessee’s law classified on the basis of sex and therefore demanded intermediate scrutiny. The state argued the law classified only by age and medical use, triggering rational-basis review. Whoever won that framing question would almost certainly win the case.

What the Court decided

Chief Justice Roberts, writing for the majority, held that Tennessee’s law does not classify on the basis of sex or transgender status (Congressional Research Service). In the majority’s reading, the statute draws two lines: by age (it restricts treatment of minors, not adults) and by medical use (it bars puberty blockers and hormones when prescribed to treat gender dysphoria, while permitting the same drugs for other diagnoses, such as early puberty or hormonal disorders). Neither line, the Court said, is a sex classification — a boy and a girl seeking these drugs for gender dysphoria are treated identically, and both are treated differently from a child prescribed them for another condition.

Because the law drew no sex-based or transgender-based classification, the majority applied rational-basis review. Under that deferential standard, it found Tennessee could reasonably cite concerns about the evidence base for these treatments in minors and about the risk of later regret. That was enough. The Court did not weigh whether Tennessee’s policy is wise or whether the medical evidence in fact supports it; rational-basis review does not ask those questions.

The plaintiffs had leaned heavily on Bostock v. Clayton County (2020), in which the Court held that firing someone for being transgender is discrimination “because of sex” under Title VII of the Civil Rights Act. The Skrmetti majority declined to carry Bostock over, reasoning that Bostock interpreted a specific employment statute and “did not purport to alter” equal-protection doctrine.

The vote was 6-3. Roberts was joined by Justices Thomas, Gorsuch, Kavanaugh, and Barrett; Justice Alito joined most of the opinion and concurred in the judgment. Justices Thomas and Barrett wrote separate concurrences — Barrett’s, joined by Thomas, arguing that transgender status should not be treated as a “suspect class” for equal-protection purposes at all. Justice Sotomayor dissented, joined by Justice Jackson and, in part, by Justice Kagan (Ballotpedia). The dissent argued the law plainly turns on sex — the permitted use of a drug depends on whether the treatment aligns with or departs from a minor’s birth sex — and warned that the majority’s framing “invites legislatures to engage in discrimination by hiding blatant sex classifications in plain sight.”

What the ruling settled

Skrmetti settled one large question and several smaller ones:

• Equal-protection challenges to these bans will fail. A claim that a minor gender-affirming-care ban violates the Equal Protection Clause as sex discrimination is now foreclosed at the federal level. That was the central legal theory behind most of the litigation against these laws, and it is closed.
• Rational-basis review governs. Because the Court treated these laws as age-and-medical-use classifications, states defending them face only the most deferential standard of review.
• The bans in effect stay in effect. Roughly 25 states’ restrictions on gender-affirming care for minors remain enforceable as a direct consequence.

What the ruling did not decide

The majority opinion was deliberately narrow, and the Court was explicit about its limits:

• It did not decide whether transgender people are a suspect or quasi-suspect class. That question — which would govern equal-protection claims well beyond health care — was raised in Barrett’s concurrence but left formally open by the majority. It can return in a future case.
• It did not address parental-rights or due-process claims. The Fourteenth Amendment’s Due Process Clause protects parents’ authority to direct their children’s medical care. Plaintiffs in some cases have argued these bans intrude on that right. Skrmetti was an equal-protection case and did not resolve the due-process theory.
• It did not address statutory anti-discrimination claims. Section 1557 of the Affordable Care Act bars sex discrimination in health programs receiving federal funds. Whether it reaches these bans is a separate question, governed by a statute rather than the Constitution, and unresolved by Skrmetti.
• It did not touch state constitutions. Every state has its own constitution, and many contain equal-protection or privacy guarantees that state courts may read more broadly than the federal Fourteenth Amendment. State-court rulings on state-constitutional grounds are not controlled by Skrmetti.

The litigation avenues that remain

The map after Skrmetti is uneven, and the unevenness is itself a sign of the avenues still open. Of the 27 states that have enacted bans, roughly 25 are in force; the bans in Arkansas and Montana have been blocked — Arkansas’s on federal due-process grounds, Montana’s under the state constitution. Those two cases illustrate the routes that survive:

• State-constitutional litigation. State courts applying state guarantees of equal protection, privacy, or parental rights can reach results the federal courts cannot. This is the most active surviving channel.
• Federal due-process and parental-rights claims. Because Skrmetti did not decide them, these theories remain live in the lower courts.
• Statutory claims, including under Section 1557, where federal funding is involved.
• Legislative action. Skrmetti holds only that the Constitution permits these bans; it does not require them. State legislatures remain free to repeal or narrow restrictions, and Congress could legislate — in either direction. The decision sets a floor of permissibility, not a national rule.

It is worth being precise about what changed. Before Skrmetti, the central federal question — whether these bans trigger heightened scrutiny as sex discrimination — was genuinely open and being litigated nationwide. It is now closed. What remains is a narrower and more fragmented set of fights, mostly in state courts and state legislatures, and mostly turning on parental rights, state constitutions, and statutory text rather than the federal Equal Protection Clause.

What to ask your representatives

• For state legislators: Skrmetti removed the constitutional ceiling but not the legislative choice. Will they support repealing or narrowing a ban — or, where none exists, do they intend to enact one?
• For members of Congress: do they support federal legislation protecting access to gender-affirming care, and how do they read Section 1557’s reach after Skrmetti?
• For state attorneys general and judicial candidates: how do they read their state constitution’s equal-protection, privacy, and parental-rights provisions, given that these are now the principal avenues left open?
• For all: do they understand that Skrmetti decided a question about levels of scrutiny — not a question about the underlying medicine — and that the policy choice still belongs to elected officials?