United States v. Skrmetti

Majority — Roberts

Joined by: Thomas, Gorsuch, Kavanaugh, Barrett, Alito

The majority held that Tennessee's law (SB1) does not classify on the basis of sex because it restricts specific medical treatments — puberty blockers and hormones used to treat gender dysphoria — for all minors regardless of their sex, and permits those same drugs for other medical purposes regardless of sex. The Court reasoned that a "medical treatment" must be understood to include both the drug and the specific condition it is treating, so banning the drug-plus-diagnosis combination of "hormones to treat gender dysphoria" is a diagnosis-based restriction, not a sex-based one. The majority also held that SB1 does not classify on the basis of transgender status, drawing an analogy to Geduldig v. Aiello (1974), in which the Court held that excluding pregnancy from disability coverage was not sex discrimination — just as not every law about pregnancy is a sex classification, not every law about gender dysphoria is a transgender-status classification. The Court declined to extend the reasoning of Bostock v. Clayton County (a Title VII employment case) to the Equal Protection context, finding that changing a minor's sex would not change SB1's outcome because the bar to treatment is the diagnosis, not the patient's sex. Finally, applying rational basis review, the Court found the law easily satisfied that standard given Tennessee's legislative findings about the experimental nature of these treatments, risks of irreversible harm, and evidence that minors may lack the maturity to fully appreciate those consequences.

Dissent reasoning

The dissent argued that SB1 plainly classifies on the basis of sex because whether a minor can receive puberty blockers or hormones depends directly on the minor's sex — a male minor can receive medications to look more like a boy, while a female minor cannot receive the same medications for the same purpose, and vice versa. Justice Sotomayor wrote that the statute's own text — prohibiting treatment that enables a minor to "identify with" an identity "inconsistent with" the minor's sex — is a facial sex classification, just as a law prohibiting attendance at religious services "inconsistent with" a child's religion would plainly classify on the basis of religion. The dissent contended that the majority's recharacterization of SB1 as a neutral "medical use" restriction is impossible to reconcile with the statute's text, because the very medical purpose SB1 prohibits is defined by reference to the patient's sex. The dissent also argued that SB1 discriminates on the basis of transgender status, because desiring to identify with a gender inconsistent with one's sex is precisely what it means to be transgender, making the affected class and the transgender class wholly coextensive. In the dissent's view, the majority's refusal to apply intermediate scrutiny — the standard the Court has used for sex-based classifications for 50 years — abandons transgender minors and their families to political majorities without the constitutional protection the Equal Protection Clause was designed to provide.