Supreme Court upholds Tennessee law restricting gender-affirming care for transgender minors

Washington — The Supreme Court on Wednesday upheld a Tennessee law that restricts access to gender-affirming care for minors experiencing gender dysphoria, clearing the way for the medical treatments for transgender youth to be limited in half of the country.

The high court ruled 6-3 in rejecting the challenge from the Biden administration, three families and a physician who had argued that Tennessee’s law violated the Constitution’s guarantee of equal protection under the law. The court concluded that the state’s measure, enacted in 2023, does not run afoul of the 14th Amendment.

“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,” Chief Justice John Roberts wrote.

The court’s majority found that Tennessee’s law is not subject to a heightened level of judicial and satisfies the most deferential standard, known as rational basis.

The three liberal justices, Sonia Sotomayor, Elena Kagan and Ketanji Brown Jackson, were in dissent. Sotomayor read her dissent from the bench.

The Tennessee law

Tennessee’s law prohibits medical treatments like puberty blockers or hormone therapy for transgender adolescents under the age of 18. The state is one of 25 with laws that seek to restrict access to gender-affirming care for young people diagnosed with gender dysphoria.

The case, U.S. v. Skrmetti, marked the first in which the Supreme Court stepped into the politically charged debate over health care for transgender youth. In addition to the state prohibitions, President Trump has issued executive orders that address what he calls “gender ideology.” One declares that it is the federal government’s policy to recognize “two sexes, male and the female,” and the second threatens federal funding for medical institutions that offer gender-affirming care to young people under the age of 18.

Mr. Trump’s proposals are being challenged in the federal courts.

Known as SB1, Tennessee’s law prevents health care providers from administering puberty blockers or hormone therapy if they’re meant to enable “a minor to identify with, or live as, a purported identity inconsistent with the minor’s sex.” The state had argued that it has a “compelling interest in encouraging minors to appreciate their sex, particularly as they undergo puberty,” and in barring treatments that “might encourage minors to become disdainful of their sex.” 

Shortly before the law took effect, three families with transgender children and a physician who provides the treatments to patients with gender dysphoria challenged the ban in federal court, arguing it is unconstitutional. The Biden administration then intervened in the case. 

A federal district court blocked the law, finding that it discriminates based on sex and transgender status. A divided panel of judges on the U.S. Court of Appeals for the 6th Circuit then reversed that decision and allowed Tennessee’s ban to take effect while legal proceedings continued.

The appeals court evaluated the law under rational-basis review, the most deferential of the tiers of judicial scrutiny. But the Biden administration and the families had argued Tennessee’s ban should be subject to a more stringent level of review, known as heightened scrutiny, because it draws lines based on sex and discriminates based on transgender status.

But Tennessee had argued that the state aims to protect young people from the consequences of the medical treatments, which it said are risky and unproven. The state said it was setting age- and use-based limits on medical care and exercising its authority to regulate medicine.

Access to gender-affirming care has become a flashpoint in the culture wars, as half of the states have in recent years enacted laws that limit the availability of the medical interventions. Many of those same states have also enacted measures prohibiting transgender athletes from competing in women’s sports.