What are the Implications of the Skrmetti Ruling for Minors’ Access to Gender Affirming Care?
On June 18, 2025, the U.S. Supreme Court ruled (6-3) in United States v. Skrmetti, upholding the lower court’s ruling that a Tennessee law (SB1) banning gender affirming care for minors does not violate the U.S Constitution’s 14th amendment equal protection clause. The Tennessee law, along with other states’ laws restricting gender affirming care, may stand. Access to gender affirming care in states without bans is not impacted by this decision.
As explained in the KFF brief, What to Know Ahead of the Supreme Court Case on Youth Access to Gender Affirming Care, the Supreme Court granted review for Skrmetti to resolve a split among circuits, and the ongoing questions about the constitutionality of these bans (see that brief for more background on the case). The question the Court considered was whether Tennessee’s ban on gender affirming care for minors violates the Equal Protection Clause of the Fourteenth Amendment. Embedded in its assessment, the Court considered whether the law results in sex-based classification and therefore should be reviewed with “heightened scrutiny” – that is, to show that the law is substantially related to achieving an important government objective – as opposed to the looser standard of “rational basis,” which only requires the state to show the law has a rational relation to the state’s legitimate objective.
What did the Court decide?
The Court found that because the Tennessee law classifies people based on age and medical diagnosis, it therefore does not discriminate on the basis of sex or transgender status and as such does not trigger heightened scrutiny. “SB1 satisfies rational basis review. Under that standard, the Court will uphold a statutory classification so long as there is “any reasonably conceivable state of facts that could provide a rational basis for the classification.”
Justice Sotomayor dissented, joined by Justice Jackson stating that because SB 1 does classify individuals based on sex, the Court should use heightened scrutiny, and SB 1 would fail under heightened scrutiny. Justice Kagan joined most parts of Justice Sotomayor’s decision except she filed a separate dissent to clarify she has no conclusion about whether SB 1 would satisfy heightened scrutiny.
What is the impact?
The result of the Court’s ruling means that most of the bans on gender-affirming care enacted by other states may stand as well. As of June 2025, 27 states that have enacted gender affirming care bans for minors. Bans in 25 states remain in place as a result of the ruling. Bans in Montana and Arkansas are currently permanently blocked by court order. The challenge in Montana relates to the state constitution and not federal law, and is therefore not directly impacted by the decision and the law remains blocked. A federal court blocked the Arkansas law, finding it unconstitutional based on both the Equal Protection and Due Process clauses. The Due Process claim was brought by parents stating the law took away their ability to make decisions regarding their child’s healthcare. This injunction remains in place given its basis on Due Process claims. The bans in Arizona and New Hampshire restrict only surgical care, which was not at issue before the Supreme Court, and remain in effect. Ultimately, this case leaves the patchwork of access to gender affirming care for young people in the United States in place. If a minor lived in a state without access before the decision, that access remains barred. If a minor had access to gender affirming care prior to the decision, that access remains.
There was some question as to whether the Court would apply the reasoning in Bostock, an earlier case which found that in the employment setting, sex discrimination protections apply to gender identity and sexual orientation in hiring and firing. But the Court did not do so, stating, “The Court declines to address whether Bostock’s reasoning reaches beyond the Title VII [employment] context—unlike the employment discrimination at issue in Bostock, changing a minor’s sex or transgender status does not alter the application of SB1.”
Notably, the Supreme Court heard this case narrowly on the basis of Equal Protection claims and many cases challenging state laws have been argued on multiple other grounds (including this case at the district and appellate courts). As noted, a federal district court has permanently blocked a similar ban on gender affirming care for minors in Arkansas, finding the ban violates the due process rights of parents of transgender minors. It is likely that additional cases will be filed against other state bans on due process grounds, and ultimately the Supreme Court could review a case in a future term raising 14th Amendment Due Process, Section 1557 (the Affordable Care Act’s major non-discrimination protections), or other claims. Additionally, as noted, the Montana Supreme Court has blocked its state ban on gender affirming care for minors based on provisions in the state constitution. Litigation challenging gender affirming care based on provisions in state constitutions will also continue in state courts, , and will likely result in varying interpretations of state constitutional protections for transgender minors.
As a result of the decision, minors across the US will continue to see their access to gender affirming care determined at least in part based on where they live. However, access to these services is being debated in venues beyond the judiciary, including in Congress and by the Trump Administration. The Trump Administration has taken a range of actions aimed at limiting access to gender affirming care, especially for minors and Congress too has taken up the issue. The reconciliation bill still being finalized includes a prohibition on Medicaid covering gender affirming care in Senate and House-passed versions. These efforts will likely face, and some cases already have faced, litigation. While the ruling on this case is quite limited (narrowly focused on equal protection claims and Tennessee’s ban), it could have some bearing on the outcome of future challenges.