The Supreme Court of the United States (the “Court”) issued its highly anticipated decision in United States v. Skrmetti (“Skrmetti“) on June 18, 2025. The decision holds that a Tennessee law prohibiting the provision of certain medical treatments to minors for gender-affirming purposes does not violate the United States Constitution. This decision has wide-ranging implications for the approximately 25 states that have enacted laws similar to Tennessee’s, and for the enforcement of recent Executive Orders restricting gender-affirming care for minors. (For more information on the Executive Orders, see our recent client alerts here and here.)
Background
In 2023, Tennessee enacted Senate Bill 1 (“SB1”), which bans the use of certain medical procedures, including hormone therapies such as puberty blockers, when provided to minors for gender affirming purposes. SB1 permits providers to provide or administer the same procedures to minors if the purpose of the treatment is to treat the minor’s congenital defect, disease (other than gender dysphoria and other gender identity diagnoses) or physical injury. Providers who furnish treatment to minors in violation of SB1 may be subject to civil penalties, licensing sanctions and private rights of action.
In April 2023, three families with transgender children and one Memphis-based physician filed suit against Tennessee, challenging the constitutionality of SB1. The District Court issued a statewide preliminary injunction of certain provisions of SB1, but the Sixth Circuit eventually stayed that preliminary injunction. The plaintiffs, supported at that time by the United States as petitioner, petitioned the United States Supreme Court for a writ of certiorari. The Court granted certiorari and heard oral arguments on December 4, 2024. On February 7, 2025, following the change in presidential administrations, the United States Solicitor General informed the Court that the United States no longer supported the plaintiffs’ position, but requested that the case be promptly resolved.
The Opinion
As a general matter, where no suspect class discrimination is made and no fundamental right is infringed, regulation of medical care is historically considered the purview of the states, and such regulations are reviewed using the highly deferential “rational basis” standard of review. The majority opinion in Skrmetti, joined by all but Justices Kagan, Sotomayor and Jackson, holds that SB1 does not discriminate on the basis of sex or transgender status, but makes classifications based only on the patient’s age and medical indications for treatment, categories that do not constitute a protected class. The Court’s majority declined to opine on whether transgender status is a protected class for purposes of Constitutional equal protection analyses. As such, the Court applied a rational basis inquiry and held that Tennessee’s stated interest in protecting the health and welfare of minors was rationally related to the age and medical indication classifications made by SB1.
Implications of This Opinion
As noted above, approximately half of all states have enacted laws restricting the provision of gender-affirming care to minors. Many of these laws are currently being litigated, as are the Executive Orders addressing gender affirming care for minors. We expect that many of these cases will be resolved in accordance with Skrmetti’s holding over the coming weeks and months.
What the Opinion Does:
- Holds that state regulations concerning gender-affirming care do not necessarily discriminate on the basis of sex or transgender status.
- Allows states to regulate gender affirming care for minors (e.g., states may restrict access regardless of parental consent or medical diagnosis).
- Establishes that states’ articulated interests in regulating gender-affirming care for minors must satisfy only a “rational basis” standard of review (e.g., Tennessee’s stated interest under SB1 was to protect the health and welfare of minors).
What the Opinion Does NOT Do:
- Opine as to whether transgender status is a protected class for the purposes of equal protection analysis.
- Impose a federal ban or restriction on access to gender-affirming care for minors.
- Rule on the specific circumstances at issue in individual pending cases at the state level.
- Affect how states regulate puberty blockers or hormone replacement therapy for minors for medical purposes other than gender dysphoria, gender identity disorder and gender incongruence.
- Opine on the reliability of any medical research regarding gender-affirming care and the effects such care may have on minors.
Practical Takeaways
Health care organizations can prepare for the implications of the Skrmetti decision by doing the following:
- Reviewing state laws regarding gender-affirming care in all states in which the organization operates, including state laws for which enforcement is currently enjoined;
- Continuing to monitor legislation and the resolution of ongoing litigation related to gender-affirming care;
- Ensuring that providers are aware of state laws restricting the provision of gender-affirming care and the penalties for violating such restrictions;
- Reviewing organizational policies regarding gender-affirming care and the treatment of minors generally to ensure compliance with applicable laws; and
- For health care organizations operating in states with few or no restrictions on gender-affirming care for minors, preparing for increased inquiries from out-of-state patients.
For questions about the Skrmetti decision, state laws governing gender affirming care for minors or related topics, please contact:
- Jennifer Skeels at (317) 977-1497 or jskeels@hallrender.com;
- Caitlin Bell-Butterfield at (919) 228-2408 or cbell-butterfiled@hallrender.com; or
- Your primary Hall Render contact.
Special thanks to Summer Associates, Meredith Johnson-Monfort and Alessandra Ruano, and Undergraduate Intern, Katelyn Howard, for their assistance in the preparation of this article.
Hall Render blog posts and articles are intended for informational purposes only. For ethical reasons, Hall Render attorneys cannot give legal advice outside of an attorney-client relationship.
