Washington — The Supreme Court on Wednesday upheld a Tennessee law that restricts access to gender-affirming care for minors experiencing gender dysphoria, a decision that is likely to have broad implications for access to medical treatments for transgender youth in half of the country.

In the case of U.S. v. Skrmetti, the high court ruled 6-3 to reject the challenge brought by 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, which is known as SB1 and was 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 review and satisfies the most deferential standard, known as rational basis.

“We are asked to decide whether SB1 is subject to heightened scrutiny under the Equal Protection Clause,” Roberts wrote. “We hold it is not. SB1 does not classify on the bases that warrant heightened review.”

The three liberal justices, Sonia Sotomayor, Elena Kagan and Ketanji Brown Jackson, were in dissent. Sotomayor read her opinion from the bench, saying “in sadness, I dissent.”

The court, Sotomayor wrote, “obfuscates a sex classification that is plain on the face of this statute, all to avoid the mere possibility that a different court could strike down SB1, or categorical healthcare bans like it.”

Joined by Kagan and Jackson, she continued: “The court’s willingness to do so here does irrevocable damage to the Equal Protection Clause and invites legislatures to engage in discrimination by hiding blatant sex classifications in plain sight. It also authorizes, without second thought, untold harm to transgender children and the parents and families who love them.”

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.

“Today’s landmark ruling by the Supreme Court is a victory for our Constitution, the rule of law, and common sense. Elected representatives have the right — and obligation — to protect children from falling victim to irreversible chemical and surgical mutilation,” Liz Huston, White House spokesperson, said in a statement. “President Trump will continue to speak out and take action to protect innocent American children from these barbaric procedures that are based on junk science.”

Attorney General Pam Bondi cheered the Supreme Court’s decision, which she said allows states to protect children.

“This Department of Justice will continue its fight to protect America’s children and parental rights. I encourage other states to follow Tennessee’s lead and enact similar legislation to protect our kids,” she said in a statement shared on social media.

The court’s decision

The Supreme Court’s conservative majority found that Tennessee’s law classifies on the basis of age and medical use, since treatments like puberty blockers and hormones can be administered to treat certain conditions, but not gender dysphoria, gender identity disorder or gender incongruence.

Classifications that turn on age or medical use are subject only to rational-basis review, the least demanding level of judicial review, it said.

“Under SB1, no minor may be administered puberty blockers or hormones to treat gender dysphoria, gender identity disorder, or gender incongruence; minors of any sex may be administered puberty blockers or hormones for other purposes,” Roberts wrote.

The majority said that Tennessee had “plausible reasons” for restricting access to gender-affirming care that brought its inquiry over the law’s constitutionality to an end, namely concerns about the health risks. The justices said they wouldn’t second-guess the legislature over the lines that the ban draws.

“Recent developments only underscore the need for legislative flexibility in this area,” Roberts wrote, pointing to a report from England’s National Health Service that evaluated the evidence regarding the use of puberty blockers and hormones and characterized it as “remarkably weak.”

“This case carries with it the weight of fierce scientific and policy debates about the safety, efficacy, and propriety of medical treatments in an evolving field,” he wrote. “The voices in these debates raise sincere concerns; the implications for all are profound. The Equal Protection Clause does not resolve these disagreements. Nor does it afford us license to decide them as we see best.”

Roberts concluded that the court’s role is only to ensure that the law does not violate the Constitution’s guarantee of equal protection.

Justices Clarence Thomas, Amy Coney Barrett and Samuel Alito all issued separate concurring opinions to express their views on the case.

Thomas said the dispute serves as a reminder that the American people and their elected officials can disagree with experts on questions of “controversial medical questions,” and courts should not sit as a “super-legislature.”

“The ongoing debate over the efficacy of sex-transition treatments for children confirms that medical and regulatory authorities are not of one mind about the treatments’ risks and benefits,” he wrote. “These conditions illustrate why states may rightly be skeptical of groups or advocates claiming that expert consensus supports their position, and why courts must exercise restraint in reviewing state legislatures’ decisions in this area.”

Barrett, meanwhile, wrote that the question of how to regulate a medical condition like gender dysphoria involves policy judgments that legislatures, not courts, are best positioned to make. She noted that transgender status implicates other areas that have been subject to regulation by states, including access to restrooms and transgender athletes’ eligibility for sports teams. If those laws are subject to a more stringent level of scrutiny, courts will then be forced to scrutinize those legislative choices, she warned.

“But legislatures have many valid reasons to make policy in these areas, and so long as a statute is a rational means of pursuing a legitimate end, the Equal Protection Clause is satisfied,” she wrote in a concurring opinion joined by Thomas.

The dissent

In her dissent, Sotomayor wrote that Tennessee’s law discriminates against transgender adolescents and conditions the availability of medications on the patient’s sex. In subjecting the law to rational-basis review, Sotomayor accused the majority of “retreating from meaningful judicial review exactly where it matters most” and abandoning “transgender children and their families to political whims.”

She said that the lower court should have evaluated the law under intermediate scrutiny because it draws lines on the basis of sex, and accused the majority of skirting its obligation to take a closer look at the ban.

Sotomayor argued that there is a history of discrimination against transgender people in health care, employment and housing, and pointed to Mr. Trump’s recent directives as evidence — namely his transgender military ban, which the Supreme Court allowed to take effect for now, and executive order seeking to ensure federal grant dollars do not promote what he calls “gender ideology.”

She accused the majority of rendering “transgender Americans doubly vulnerable to state-sanctioned discrimination,” and said the high court could have ordered the 6th Circuit to apply the more stringent standard of review without wading into scientific and policy debates over the safety of medical treatments for minors experiencing gender dysphoria.

“Yet the majority inexplicably refuses to take even the modest step of requiring Tennessee to show its work before the lower courts,” Sotomayor wrote.

The ACLU and Lambda Legal, which represented the transgender adolescents and their families, lamented the Supreme Court’s decision as a loss for transgender youth.

“Today’s ruling is a devastating loss for transgender people, our families, and everyone who cares about the Constitution,” said Chase Strangio, a co-director of the ACLU’s LGBTQ & HIV Project who participated in arguments before the Supreme Court. “Though this is a painful setback, it does not mean that transgender people and our allies are left with no options to defend our freedom, our health care, or our lives.”

Tennessee can ban gender transition treatments for minors, a divided Supreme Court ruled Wednesday in a landmark decision on a polarizing issue the Trump administration has seized on as it targets transgender rights. In one of the most high-profile cases of the term, the court voted 6-3 along ideological lines to uphold the state law that prohibits adolescents from using hormones and puberty blockers for gender transition.

The decision, authored by Chief Justice John G. Roberts Jr., has implications for more than 20 other states that have banned similar treatments as a growing — but still small — number of young people seek gender transition care. The ruling appears to leave opportunities for advocates to challenge other policies restricting access for transgender individuals to bathrooms, sports participation, military service and health care.

Advertisement

Roberts said Tennessee’s law does not discriminate on the basis of sex and that courts must give elected officials wide discretion to pass legislation when there is scientific and policy debate about the safety of medical treatments in an evolving field. He acknowledged that “The voices in these debates raise sincere concerns; the implications for all are profound.”

Having concluded the law, which applies only to minors, does not violate the Constitution, Roberts wrote, “We leave questions regarding its policy to the people, their elected representatives, and the democratic process.”

The court’s three liberal justices dissented from the majority’s decision. Justice Sonia Sotomayor read a lengthy summary of her dissent from the bench, saying Tennessee’s law banned lifesaving medical treatment and plainly discriminates.

Advertisement

“By retreating from meaningful judicial review exactly where it matters most, the Court abandons transgender children and their families to political whims,” Sotomayor wrote, adding: “In sadness, I dissent.”

The ruling is only the second time the Supreme Court has addressed transgender rights. In Bostock v. Clayton County in 2020, the court said an employer who fires a worker “merely for being gay or transgender” unlawfully discriminates “because of such individual’s sex.”

The transgender teens, their parents and a doctor who sued over the Tennessee law pointed to the Bostock ruling in asserting that the treatment ban was discriminatory. But the court’s 6-3 decision Wednesday left for another day the question of whether the reasoning in Bostock applies outside of employment discrimination. The justices also have not yet grappled with looming legal questions about transgender athletes and access to bathrooms for transgender individuals.

Advertisement

In a statement, Tennessee Attorney General Jonathan Skrmetti praised the decision as a win for Tennessee voters and the lawmaking process.

“A bipartisan supermajority of Tennessee’s elected representatives carefully considered the evidence and voted to protect kids from irreversible decisions they cannot yet fully understand,” Skrmetti said.

ACLU attorney Chase Strangio, who represented the families behind the court challenge, called the ruling a painful setback “for transgender people, our families, and everyone who cares about the Constitution.”

“We are as determined as ever to fight for the dignity and equality of every transgender person and we will continue to do so with defiant strength, a restless resolve, and a lasting commitment to our families, our communities, and the freedom we all deserve,” said Strangio, the first openly transgender attorney to argue before the court.

Advertisement

Cathryn Oakley, senior director of legal policy for the Human Rights Campaign, said that while the ruling was “devastating and really scary” for families with trans children, both the question before the Supreme Court and its ruling were somewhat narrow.

“There are a lot of remaining legal pathways to challenge these laws,” Oakley said. “My heart is broken for these kids who are not going to be able to receive the medical care they need to thrive and be well, but it’s not over by any stretch.”

Soon after returning to the White House, President Donald Trump signed orders to halt transgender or nonbinary passport applications, transfer incarcerated trans women to solitary confinement and cut off young people’s access to gender transition care nationwide.

Those efforts have mostly been blocked by courts. But the justices have allowed the administration to bar transgender troops from serving in the military while litigation continues. And Trump continues to push new policies targeting LGBTQ young people. On Tuesday evening, the administration ordered The Trevor Project to shut down a suicide and crisis hotline for LGBTQ youth.

Advertisement

Attorney General Pam Bondi applauded the court’s decision in a post on X and encouraged other states to “follow Tennessee’s lead and enact similar legislation to protect our kids.”

The Supreme Court’s ruling in the Tennessee case will provide direction to lower courts that are also grappling with similar issues. An appeals court in Ohio in March blocked the state’s ban on treatments for young people, finding the law “unconstitutional on its face.”

The Tennessee statute adopted in 2023 prohibits young people from using hormones and puberty blockers for gender transition. Most leading medical organizations say the treatments are safe and effective. But some European countries have raised concerns.

Tennessee has characterized the treatments as unproven and risky, and the high court’s conservative majority pointed to the uncertainty in its ruling.

Advertisement

Hans von Spakovsky, senior legal fellow at the conservative Heritage Foundation, praised the Supreme Court for recognizing the “right of states to protect their children from hazardous medical procedures” and the Trump administration for reversing the position of the Biden administration in court.

Seven major U.S. medical associations, including the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists, called Wednesday’s ruling disappointing and said it “strips patients and families of the choice to direct their own health care.”

At issue for the justices was whether Tennessee’s law, which says the state has an interest in “encouraging minors to appreciate their sex” and in prohibiting treatments that “might encourage minors to become disdainful of their sex,” violates the equal protection clause of the Constitution.

Advertisement

The challengers had asked the Supreme Court to find that the law amounts to sex discrimination and should be subject to a higher standard of legal review than the lower court applied. That standard would have made it more difficult for the state to justify the ban.

The U.S. Court of Appeals for the 6th Circuit in 2023 upheld the law as constitutional, saying it bars gender transition treatments for all minors, regardless of sex. That ruling concluded that state lawmakers could have rationally determined that the law was an appropriate response to perceived risks associated with the treatments.

The Supreme Court affirmed that decision Wednesday, ruling that the law — which says no minor may be administered puberty blockers or hormones to treat gender dysphoria, gender identity disorder, or gender incongruence — treats all transgender boys and transgender girls the same way.

Advertisement

“The law does not prohibit conduct for one sex that it permits for the other,” wrote Roberts, who was joined in full by Justices Clarence Thomas, Neil M. Gorsuch, Brett M. Kavanaugh and Amy Coney Barrett.

The majority also said courts should not second-guess state lawmakers in an area of scientific debate. The opinion pointed to some European countries that have raised concerns about potential harms for young people using puberty blockers and hormones and studies showing insufficient data about the long-term effects. U.S. experts have disputed the characterization of some of those European findings.

“Tennessee concluded that there is an ongoing debate among medical experts regarding the risks and benefits associated with administering puberty blockers and hormones,” Roberts wrote, saying the ban “responds directly to that uncertainty.”

Justice Samuel A. Alito Jr. agreed with the majority’s judgment and wrote separately to explain his reasoning.

In dissent, Sotomayor agreed with the Biden administration and the American Civil Liberties Union that the Tennessee law discriminates based on sex because an adolescent assigned female at birth, for instance, cannot receive puberty-delaying treatments or testosterone to live as a male, but an adolescent assigned male at birth could receive such treatments.

“By depriving adolescents of hormones and puberty blockers only when such treatment is ‘inconsistent with’ a minor’s sex, the law necessarily deprives minors identified as male at birth of the same treatment it tolerates for an adolescent identified as female at birth (and vice versa),” wrote Sotomayor, joined by Justice Ketanji Brown Jackson and in part by Justice Elena Kagan.

She invoked two landmark Supreme Court decisions that eliminated discriminatory policies and said the majority was shirking its responsibility. In Loving v. Virginia, the court struck down bans on interracial marriage. In United States v. Virginia, the court ruled that the Virginia Military Institute’s male-only admissions policy was unconstitutional.

“Those laws, too, posed politically fraught and contested questions about race, sex, and biology,” Sotomayor wrote.

Sotomayor said the majority should have sent the Tennessee case back to the appeals court to determine whether a categorical ban on the treatments sufficiently protects the health of transgender teens or, instead, rests on unlawful stereotypes about how boys and girls should look and act. The justice noted that if left untreated, gender dysphoria can lead to severe depression, anxiety and self-harm.

The majority, Sotomayor wrote, “authorizes, without second thought, untold harm to transgender children and the parents and families who love them.”

Surveys have found that roughly 40 percent of transgender youths nationwide — and 93 percent of transgender youths in the South — live in states with a ban. Only a small percentage of trans minors receive medications as part of their treatment.

Though many families with trans kids have moved because of the bans, many others either can’t or do not want to relocate, said Jasmine Beach-Ferrara, executive director of Campaign for Southern Equality. Instead, they travel long distances every few months for follow-up appointments and prescription refills.

Over the past two years, Beach-Ferrara’s Asheville, North Carolina-based organization has spent $600,000 to help 1,200 families travel for medical care, sometimes up to four times a year. Though Beach-Ferrara said her organization will continue to raise money to do that work, she said Wednesday’s ruling “has compounding effects beyond the realm of health care.”

“It impacts the climate in schools,” Beach-Ferrara said. “It impacts the climate in communities, because it sends an incredibly harmful and fundamentally incorrect, untrue message about who trans young people are and what they deserve.”

West Virginia Attorney General JB McCuskey said Wednesday that he intends to use the ruling to shape his argument in other trans-related cases concerning sports and Medicaid coverage.

But across New England where all states but New Hampshire have passed laws protecting access to transgender care, those rights will remain in place, said Jennifer Levi , GLAD Law senior director of transgender and queer rights.

The 6-3 decision will affect Tennessee and 26 other states that already prohibit medication or surgical care for transgender youth, effectively protecting those laws.

The US Supreme Court Wednesday upheld a Tennessee ban on gender-affirming care for children and adolescents, in a ruling decried as “devastating,” “heartbreaking,” and “cruel” by advocates for transgender rights.

“Nothing in this decision prevents care from being provided in states that do not have bans,” she said. “So for the half of the country that does not have bans, that care should and will continue to be provided.”

Advertisement

Though the country is sharply divided on this issue, Levi said she doesn’t expect this decision to fuel additional state bans regarding transgender care. Nor does the decision address the many contentious issues that remain regarding transgender rights, such as in schools or athletics.

Get Starting Point A guide through the most important stories of the morning, delivered Monday through Friday. Enter Email Sign Up

With this decision, the court is putting its stamp on a national political debate that played an instrumental role in last fall’s election.

Leor Sapir, a political scientist fellow at the Manhattan Institute and critic of the American approach to gender-affirming care, said the Supreme Court decision is a rebuke to a medical establishment that he said has failed to critically evaluate the evidence for and against the benefits of such care for young people.

Advertisement

He said the US has leaned too heavily in favor of gender-affirming care without guardrails. That drew court involvement into a debate that he believes should have been addressed by more critical discussion within the medical community.

“My hope is that this ruling will draw attention to the controversy itself and force those institutions that have disallowed a debate, disallowed dissent, to consider different perspectives,” Sapir said.

But some advocates and medical specialists said they feared the decision would send a devastating message to young people who are seeking or considering gender-affirming care — even in states where it’s protected. They also said they expect the ruling to trigger an influx of patients from states that prohibit such care to Massachusetts and other places that allow it.

“I am sincerely worried about the signal that this sends to young people who are living in such a hostile political climate,” said Dr. Meredithe McNamara, an assistant professor of pediatrics at the Yale School of Medicine and a physician who cares for transgender youth.

McNamara said the expected flow of new patients to Massachusetts and other transgender-accepting states may limit health providers’ ability to offer timely care.

“It’s not really an option for people receiving this care to stop it — just like you wouldn’t stop breathing or wouldn’t stop eating,” she said.

At Fenway Health in Boston, which has long offered care to the LGBTQ and trans community across New England, the expectation is that more people will walk through its doors because of the decision, especially from New Hampshire, which is considering a law similar to the one in Tennessee. The New Hampshire bill would expand a ban the state passed last year on gender-affirming genital surgeries for minors.

Advertisement

Fenway has gradually seen an increase in patients from out of state seeking gender-affirming care since the election, said Julie Thompson, Fenway’s interim associate medical director and medical director of trans health.

She is concerned that Wednesday’s decision may fuel anxieties among some young people in Massachusetts about traveling out of state for fear they wouldn’t be able to receive needed medical care elsewhere.

“My patients are nervous, they’re scared,” she said. “Any time people’s identities or lives are debated in the public sphere, it causes a lot of mental health distress.”

That anxiety isn’t limited to young patients. There is concern in the trans community, she said, that the court decision for children could be a prelude to an effort to limit or ban gender-affirming care for adults, too. The decision is seen as walking back protections the trans community has gained over a period of years.

“Though this is specific to youth, there’s kind of a real fear this has kind of cracked the door open,” she said.

Deborah, the mother of a 10-year-old transgender girl in Boston who is just starting consultations with endocrinologists and psychologists, said she probably will not tell her daughter about the Supreme Court ruling. She is concerned, however, that the youngster may see references to it on YouTube.

“I am not sure it would be helpful for her to know,” said Deborah, who asked that her full name not be used to protect her daughter’s privacy. “My job as a mom is to help her feel safe and secure and not paralyzed by fear all the time.”

Advertisement

Deborah volunteers at Greater Boston PFLAG, an LGBTQ advocacy organization, and said she would like the group to consider helping people in other states gain access to care.

“I can’t imagine telling your kid they can’t get the medical care they need to feel good in their bodies,” she said. “Maybe we will connect with people in other states that don’t have protections to see if there are things we can do, underground railroad style.”

Gender-affirming care is overwhelmingly supported by the American medical establishment, which considers it safe and effective. But other countries have different positions.

The Cass Report last year to Great Britain’s National Health Service concluded there wasn’t strong evidence of the effectiveness of gender-affirming care and recommended against hormone treatments for patients under 18. Thompson, from Fenway Health, noted the author of that report had no experience providing gender-affirming care and said the report didn’t look at the outcomes for patients reported in the studies it reviewed. Meanwhile, a study released last month by the Utah Department of Health and Human Services concluded that gender-affirming care for youth improves patient well-being and that there is no scientific reason to deny teens hormone therapies.

A chorus of Massachusetts lawmakers and leaders reiterated their support Wednesday for protecting transgender rights.

Senate President Karen E. Spilka told reporters at the State House that transgender care is “a strong Massachusetts value” and one that’s “even more important than it was yesterday.”

The chamber is teeing up a vote for next week on a bill legislators said is designed to protect those who offer gender-affirming and reproductive care in Massachusetts. The legislation would, in part, bar state agencies from cooperating with federal law-enforcement or providing them with information for investigations into so-called legally protected health care. It would also exempt the personal information of those who provide or promote gender-affirming and reproductive health care from the state’s public records law.

Advertisement

“We will protect our residents, defend Massachusetts values, and help lead us out of these dark times,” Spilka, an Ashland Democrat, said.

Yet the Supreme Court decision did provide a tiny ray of hope for challengers who can demonstrate that the purpose of a state ban is a desire to harm transgender people.

“It does create pathways forward for challenging laws in places where it is clear from the facts that the purpose of the ban is to harm a vulnerable group, in this case, transgender adolescents,” said Levi, from GLAD Law.

But, she said, she does not mean to “sugar coat” the reality now for thousands of families across the country.

“This puts parents in those states where the care is banned in an excruciatingly difficult position,” she said, “because it is very difficult for them to get the care that their children need.”

Claire Thornton and Matt Stout of the Globe staff contributed to this report.

Kay Lazar can be reached at kay.lazar@globe.com Follow her @GlobeKayLazar. Jason Laughlin can be reached at jason.laughlin@globe.com. Follow him @jasmlaughlin. Emily Spatz can be reached at emily.spatz@globe.com. Follow her on X @emilymspatz.

June 18, 2025 — In a divisive decision, the U.S. Supreme Court ruled 6-3 in United States v. Skrmetti to uphold a Tennessee law banning gender-affirming care for transgender youth, delivering what advocates have called a major blow to civil rights, public health, and medical freedom.

The ruling affirms the Sixth Circuit’s decision allowing Senate Bill 1 to take effect, a law that prohibits doctors from prescribing puberty blockers, hormone therapy, or performing surgeries on minors if done to treat gender dysphoria. The Court concluded that the law does not violate the Equal Protection Clause of the Fourteenth Amendment.

In the majority opinion written by Chief Justice John Roberts, the Court determined that the law’s classifications are based not on sex or gender identity but rather on age and the type of medical diagnosis involved.

The decision subjects the law to rational basis review—the most deferential standard of judicial scrutiny—and finds the statute constitutionally sound under that lens. Roberts wrote that the state legislature has wide discretion in regulating medical treatments and cited ongoing debate in the medical community regarding the long-term impacts of puberty blockers and hormone therapies on minors.

The majority opinion asserted that because the law applies to all minors regardless of their sex and permits these treatments for other conditions such as precocious puberty or congenital defects, it does not discriminate on the basis of sex or transgender status.

“The Equal Protection Clause does not resolve these disagreements,” Roberts wrote, “Nor does it afford us license to decide them as we see best. 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.”

In a searing dissent, Justice Sonia Sotomayor, joined by Justices Elena Kagan and Ketanji Brown Jackson, condemned the ruling as an abandonment of transgender youth in the face of political hostility.

“In sadness, I dissent,” Sotomayor declared from the bench, an act rarely taken that underscored the depth of her disapproval.

Her opinion argued that Tennessee’s law constitutes explicit discrimination based on sex and transgender status, noting that the same medical treatments banned for trans youth are allowed for cisgender minors with other diagnoses.

Sotomayor wrote that the law penalizes transgender youth for not conforming to sex-based stereotypes and conditions their access to care on their assigned sex at birth. She rejected the majority’s framing that the law merely distinguishes based on age and medical use, contending that the true effect and purpose of the law is to deny medically necessary care to a marginalized group.

“This Court fails the families who relied on its protection. It fails the medical providers who are risking their livelihoods to uphold their oath. And it fails our constitutional tradition of protecting the vulnerable against the will of the majority,” she wrote.

Justice Kagan, in a separate dissent, criticized the Court for failing to apply intermediate scrutiny, the level of review historically used for laws that classify on the basis of sex.

“I take no view on how SB1 would fare under heightened scrutiny,” she wrote, “but the Court is wrong in not subjecting it to that kind of examination. That error requires reversal.”

The decision has immediate and far-reaching consequences. More than 25 states have passed similar bans since 2021, and over 100,000 transgender minors now live in jurisdictions where access to gender-affirming medical care is restricted or prohibited. The ruling gives legal cover to those bans and could embolden efforts to restrict trans health care even further.

The majority’s opinion places significant weight on recent developments in Europe, such as the Cass Review in the United Kingdom and restrictions in Sweden, Finland and Norway, which have called for tighter controls on gender-affirming treatment for minors.

Justice Clarence Thomas, in a concurring opinion, dismissed the notion of a medical consensus on these treatments, warning against judicial reliance on what he called “self-described experts in politically contentious debates.”

The case originated from a lawsuit brought by three transgender teenagers, their parents, and a Memphis-based physician, Dr. Susan Lacy, all of whom argued that the law violated the Equal Protection Clause by denying essential health care to transgender adolescents.

The U.S. Department of Justice initially joined the plaintiffs in challenging the law during the Biden administration, arguing that SB1 amounted to unlawful discrimination.

But following President Donald Trump’s return to office, the federal government reversed its position, aligning with Tennessee and asserting that the law does not violate the Constitution.

In response to the ruling, California Attorney General Rob Bonta issued a statement reaffirming California’s unwavering support for trans youth and their families.

“All Americans, regardless of their gender identity, have the inalienable right to equal protection under the law. This includes the right to access healthcare free from discrimination,” Bonta said. “Across the nation, we’ve seen a rise in hate-fueled violence and intimidation against our LGBTQ+ community, and laws such as Tennessee’s Senate Bill 1 only serve to exacerbate these conditions by blatantly discriminating against transgender youth and denying them access to critical life-saving care. In California, we will continue to promote and protect access to healthcare, not restrict it.”

California State Senator Scott Wiener, author of the state’s landmark “trans refuge” law and sponsor of additional protections under Senate Bill 497, called the ruling “horrifying” and accused the Court of giving extremists a “permission slip” to erase trans people from public life.

“Major medical associations have been crystal clear that this care is appropriate and medically necessary,” Wiener said. “Only a tiny percentage of trans youth receive this care, and the kids who receive it overwhelmingly do so with the consent and support of their parents. Yet Trump and his cult have created a moral panic based on lies—and the Court has validated their campaign to criminalize parents and doctors.”

National civil rights groups responded to the decision with condemnation and renewed vows to fight back.

Chase Strangio, deputy director for transgender justice at the American Civil Liberties Union, called the ruling “a painful setback,” but emphasized that the Court’s opinion is limited to the specific legal theory under review and does not foreclose future challenges.

“Though this is a painful setback, it does not mean that transgender people and our allies are left with no options to defend our freedom, our health care, or our lives,” Strangio said. “We are as determined as ever to fight for the dignity and equality of every transgender person.”

Sasha Buchert, director of the Nonbinary and Transgender Rights Project at Lambda Legal, said the ruling will “reverberate for years” but vowed continued litigation.

“Make no mistake—gender-affirming care is often life-saving care, and all major medical associations have determined it to be safe, appropriate, and effective,” Buchert said. “We will continue to fight fiercely to protect transgender youth and their families.”

The implications for families are stark. The ACLU of Tennessee, a plaintiff in the case, warned that the decision creates a “class of people who politicians believe deserve healthcare, and a class of people who do not.” The law could force families to leave their home states in order to secure medical care for their children. Others may face prosecution or investigation under new laws that criminalize efforts to seek gender-affirming care across state lines.

Medical experts remain united in their opposition to bans like SB1. The American Medical Association, the American Academy of Pediatrics, and the American Psychiatric Association have all warned that denying gender-affirming care increases the risk of depression, self-harm, and suicide among trans youth. These organizations emphasize that such care is provided only after thorough evaluation and with parental consent, and that surgeries for minors are exceedingly rare.

Despite the overwhelming medical consensus, the Court’s decision underscores a broader trend: growing judicial deference to legislatures in matters of science, medicine, and civil rights—particularly when the groups affected lack political power.

The ruling also reflects a broader strategy by Republican-led states and the Trump administration to restrict transgender rights through executive orders, legislation, and now judicial validation.

In the wake of the decision, progressive states like California and New York have vowed to continue serving as sanctuaries for transgender youth and their families. Lawmakers in both states are advancing measures to protect patient data, shield healthcare providers from out-of-state legal action, and expand access to gender-affirming services.

Categories:

The Williams family sued in 2023 after access to gender-affirming care for transgender teenagers was banned in Tennessee.

The U.S. government initially argued against Tennessee’s law, before flipping positions after President Donald Trump took office.

The ruling will likely set broad precedent on how constitutional protections apply to transgender people.

The U.S. Supreme Court in a 6-3 decision upheld Tennessee’s ban on gender transition treatments for transgender minors in a case brought by a Nashville family.

The ruling comes six months after the high court heard arguments in the case that will likely have broad ripple effects for transgender youth across the nation, not just for the family who initially challenged the state in 2023.

Chief Justice John Roberts, writing the majority opinion, found that Tennessee’s law barring transgender minors from using treatments like puberty blockers and hormone therapy does not violate the Equal Protection Clause of the Constitution, which requires that the government treat similarly situated people the same.

“This case carries with it the weight of fierce scientific and policy debates about the safety, efficacy, and propriety of medical treatments in an evolving field,” Roberts wrote. “The voices in these debates raise sincere concerns; the implications for all are profound. The Equal Protection Clause does not resolve these disagreements. Nor does it afford us license to decide them as we see best.”

Roberts wrote, “we leave questions regarding (the law’s) policy to the people, their elected representatives, and the democratic process.” The ruling will likely keep in effect laws similar to Tennessee’s that have been enacted in 26 other states, according to the Liberty Counsel, an evangelical Christian legal group.

Reactions to the ruling

Tennessee Attorney General Jonathan Skrmetti’s office defended the law in court. He said in a statement “the common sense of Tennessee voters prevailed over judicial activism.”

“A bipartisan supermajority of Tennessee’s elected representatives carefully considered the evidence and voted to protect kids from irreversible decisions they cannot yet fully understand,” he said. “I commend the Tennessee legislature and Governor Lee for their courage in passing this legislation and supporting our litigation despite withering opposition from the Biden administration, LGBT special interest groups, social justice activists, the American Medical Association, the American Bar Association, and even Hollywood.”

Gov. Bill Lee, in a statement, thanked Skrmetti for securing the “historic ruling” and said the legislation is intended to protect young people.

“Protecting children is a fundamental responsibility that we take seriously, and I was proud to sign this bipartisan legislation that lawfully safeguards young people from irreversible, life-altering medical decisions,” Lee’s statement reads. “Voters, through their elected representatives, should have the power to decide what they believe on serious issues like this one.”

Tennessee Senate Minority Leader Raumesh Akbari, D-Memphis, called the ruling a harmful setback for “anyone who believes in the basic freedom to make personal medical decisions without government interference.”

““Tennessee’s law was always about politics, not protecting children,” Akbari said. “It strips away the rights of loving families and qualified professionals to make decisions based on science and compassion. Now, the highest court in the land has greenlit that overreach, opening the door for even more intrusion into private healthcare choices.”

Justices Sonia Sotomayor, Elena Kagan and Ketanji Brown Jackson dissented. Sotomayor wrote that the court’s decision does “irrevocable damage to the Equal Protection Clause and invites legislatures to engage in discrimination by hiding blatant sex classifications in plain sight.”

“It also authorizes, without second thought, untold harm to transgender children and the parents and families who love them,” she wrote. “Because there is no constitutional justification for that result, I dissent.”

Advocacy groups were disappointed in the ruling.

The Tennessee Equality Project, a statewide nonprofit advocating for LGBTQ+ rights, said in a statement, “equal access to health care and bodily autonomy are fundamental human rights for every person, including our transgender children and youth.” The American Academy of Pediatrics, the largest professional association of pediatricians in the U.S., supports the use of gender-affirming medical care, the Tennessee Equality Project said.

“The consequences of this devastating decision will be felt by anyone who needs gender-affirming care; worse for transgender patients already facing widespread discrimination in hostile states,” the group’s statement reads.

While the ruling allows states to bar access to gender-affirming treatment for minors, the court left other protections for transgender people in place, the American Civil Liberties Union noted in its statement.

“Though this is a painful setback, it does not mean that transgender people and our allies are left with no options to defend our freedom, our health care, or our lives,” Chase Strangio, co-director of the ACLU’s LGBTQ and HIV Project. “The Court left undisturbed Supreme Court and lower court precedent that other examples of discrimination against transgender people are unlawful.”

Family filed suit over Tennessee law

Samantha and Brian Williams, along with their teenage daughter identified in court documents as L, sued after Republicans lawmakers banned medications like puberty blockers and hormone therapy to treat gender dysphoria.

The ban blocked L from receiving prescriptions, but other Tennessee teens can be prescribed the same medications, as long as they’re not transgender.

“Puberty has a lot of irreversible damage that comes with it,” L told The Tennessean in 2024. “So, I think to say that you should wait to make the decision until you’re 18 has a lot of consequences and permanent aspects to it.”

The 2023 law also banned gender transition surgeries for minors, which were rare in the state. The surgical ban was not debated in the Supreme Court case.

The Supreme Court in the past upheld the legality of a California insurance program that excluded from coverage certain health issues that result from pregnancy. Rather than discriminating based on sex, the program discriminated based on pregnancy status, and non-pregnant people include both men and women, the court decided in that case.

“By the same token, SB1 does not exclude any individual from medical treatments on the basis of transgender status,” the majority wrote. “Rather, it removes one set of diagnoses — gender dysphoria, gender identity disorder, and gender incongruence — from the range of treatable conditions.”

Because the law does not distinguish between people based on sex or transgender status, the law is not subject to a stricter legal standard called heightened scrutiny, the court said.

The new Tennessee law threw L’s treatment into disarray, as her parents raced to find medical care in other states as similar laws began falling across the country. L eventually established medical treatment in North Carolina and was grandfathered in before the state passed its own ban.

The Williams family was initially successful in challenging Tennessee’s ban.

A Nashville-based federal court sided with the Williams family and other plaintiffs, finding the state likely did not craft its law without infringing on constitutional rights, while the state said Republican lawmakers passed the law to protect kids from serious medical risk. The 6th Circuit Court of Appeals sided with the state and overturned an injunction blocking the law.

Case expected to set precedent

The case is expected to set a precedent for how constitutional protections against sex discrimination — the 14th Amendment’s Equal Protection clause — can be applied for transgender people. The ruling does not, however, mean gender-affirming care is banned nationwide.

The ruling also does not necessarily mean all bans on gender-affirming care for minors cannot be challenged legally, according to Karen Loewy, director of constitutional law practice at Lambda Legal, a civil rights organization for LGBTQ+ people.

“There is nothing in this opinion that is a mandate,” Loewy said in a virtual news conference after the decision was released. “There’s nothing in this opinion that is a green light for others to join the bandwagon here of discriminating against trans young people.”

In the Supreme Court arguments, attorneys for the plaintiffs and the U.S. Department of Justice argued Tennessee’s ban ran afoul of constitutional protections. The federal government later flipped its position on the case, however, after President Donald Trump took office in January.