UNITED STATES v. SKRMETTI, ATTORNEY GENERAL AND REPORTER FOR TENNESSEE, ET AL.
No. 23-477
SUPREME COURT OF THE UNITED STATES
June 18, 2025
605 U. S. ____ (2025)
CERTIORARI TO THE UNITED STATES COURT OF APPEALS FOR THE SIXTH CIRCUIT
Argued December 4, 2024—Decided June 18, 2025
(Slip Opinion) OCTOBER TERM, 2024 1
Syllabus
NOTE: Where it is feasible, a syllabus (headnote) will be released, as is being done in connection with this case, at the time the opinion is issued. The syllabus constitutes no part of the opinion of the Court but has been prepared by the Reporter of Decisions for the convenience of the reader. See United States v. Detroit Timber & Lumber Co., 200 U. S. 321, 337.
SUPREME COURT OF THE UNITED STATES
Syllabus
UNITED STATES v. SKRMETTI, ATTORNEY GENERAL AND REPORTER FOR TENNESSEE, ET AL.
No. 23–477. Argued December 4, 2024—Decided June 18, 2025
In 2023, Tennessee joined the growing number of States restricting sex transition treatments for minors by enacting the Prohibition on Medical Procedures Performed on Minors Related to Sexual Identity, Senate Bill 1 (SB1). SB1 prohibits healthcare providers from prescribing, administering, or dispensing puberty blockers or hormones to any minor for the purpose of (1) enabling the minor to identify with, or live as, a purported identity inconsistent with the minor’s biological sex, or (2) treating purported discomfort or distress from a discordance between the minor’s biological sex and asserted identity. At the same time, SB1 permits a healthcare provider to administer puberty blockers or hormones
Three transgender minors, their parents, and a doctor challenged SB1 under the Equal Protection Clause of the Fourteenth Amendment. The District Court partially enjoined SB1, finding that transgender individuals constitute a quasi-suspect class, that SB1 discriminates on the basis of sex and transgender status, and that SB1 was unlikely to survive intermediate scrutiny. The Sixth Circuit reversed, holding that the law did not trigger heightened scrutiny and satisfied rational basis review. This Court granted certiorari to decide whether SB1 violates the Equal Protection Clause.
Held: Tennessee’s law prohibiting certain medical treatments for transgender minors is not subject to heightened scrutiny under the Equal Protection Clause of the Fourteenth Amendment and satisfies rational basis review. Pp. 8–24.
(a) SB1 is not subject to heightened scrutiny because it does not classify on any bases that warrant heightened review. Pp. 9–21.
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(1) On its face, SB1 incorporates two classifications: one based on age (allowing certain medical treatments for adults but not minors) and another based on medical use (permitting puberty blockers and hormones for minors to treat certain conditions but not to treat gender dysphoria, gender identity disorder, or gender incongruence). Classifications based on age or medical use are subject to only rational basis review. See Massachusetts Bd. of Retirement v. Murgia, 427 U. S. 307 (1976) (per curiam); Vacco v. Quill, 521 U. S. 793.
The plaintiffs argue that SB1 warrants heightened scrutiny because it relies on sex-based classifications. But neither of the above classifications turns on sex. Rather, SB1 prohibits healthcare providers from administering puberty blockers or hormones to minors for certain medical uses, regardless of a minor’s sex. While SB1’s prohibitions reference sex, the Court has never suggested that mere reference to sex is sufficient to trigger heightened scrutiny. And such an approach would be especially inappropriate in the medical context, where some treatments and procedures are uniquely bound up in sex.
The application of SB1, moreover, does not turn on sex. The law does not prohibit certain medical treatments for minors of one sex while allowing those same treatments for minors of the opposite sex. SB1 prohibits healthcare providers from administering puberty blockers or hormones to any minor to treat gender dysphoria, gender identity disorder, or gender incongruence, regardless of the minor’s sex; it permits providers to administer puberty blockers and hormones to minors of any sex for other purposes. And, while a State may not circumvent the Equal Protection Clause by writing in abstract terms, SB1 does not mask sex-based classifications.
Finally, the Court rejects the plaintiffs’ argument that, by design, SB1 enforces a government preference that people conform to expectations about their sex. To start, any allegations of sex stereotyping are misplaced. True, a law that classifies on the basis of sex may fail heightened scrutiny if the classifications rest on impermissible stereotypes. But where a law’s classifications are neither covertly nor overtly based on sex, the law does not trigger heightened review unless it was motivated by an invidious discriminatory рurpose. No such argument has been raised here. And regardless, the statutory findings on which SB1 is premised do not themselves evince sex-based stereotyping. Pp. 9–16.
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that a California insurance program that excluded from coverage certain disabilities resulting from pregnancy did not discriminate on the basis of sex. See id., at 486, 492–497. In reaching that holding, the Court explained that the program did not exclude any individual from benefit eligibility because of the individual’s sex but rather “remove[d] one physical condition—pregnancy—from the list of compensable disabilities.” Id., at 496, n. 20. The California insurance program, the Court explained, divided potential recipients into two groups: “pregnant women and nonpregnant persons.” Ibid. Because women fell into both groups, the Court reasoned, the program did not discriminate against women as a class. See id., at 496, and n. 20. The Court concluded that, even though only biological women can become pregnant, not every legislative classification concerning pregnancy is a sex-based classification. Id., at 496, n. 20. As such, “[a]bsent a showing that distinctions involving pregnancy are mere pretexts designed to effect an invidious discrimination against the members of one sex or the other, lawmakers are constitutionally free to include or exclude pregnancy from the coverage of legislation . . . on any reasonable basis, just as with respect to any other physical condition.” Id., at 496–497, n. 20.
By the same token, SB1 does not exclude any individual from medical treatments on the basis of transgender status. Rather, it removes one set of diagnoses—gender dysphoria, gender identity disorder, and gender incongruence—from the range of treatable conditions. SB1 divides minors into two groups: those seeking puberty blockers or hormones to treat the excluded diagnoses, and those seeking puberty blockers or hormones to treat other conditions. While the first group includes only transgender individuals, the second encompasses both transgender and nontransgender individuals. Thus, although only transgender individuals seek treatment for gender dysphoria, gender identity disorder, and gender incongruence—just as only biological women can become pregnant—there is a “lack of identity” between transgender status and the excluded diagnoses. Absent a showing that SB1’s prohibitions are pretexts designed to effect invidious discrimination against transgender individuals, the law does not classify on the basis of transgender status. Pp. 16–18.
(3) Finally, Bostock v. Clayton County, 590 U. S. 644, does not alter the Court’s analysis. In Bostock, the Court held that an employer who fires an employee for being gay or transgender violates Title VII’s prohibition on discharging an individual “because of” their sex. See id., at 650–652, 654–659. The Court reasoned that Title VII’s “because of” test incorporates the traditional but-for causation standard, which directs courts “to change one thing at a time and see if the outcome changes.” Id., at 656. Applying that test, the Court held that, “[f]or an employer to discriminate against employees for being homosexual or
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transgender, the employer must intentionally discriminate against individual men and women in part because of sex.” Id., at 662. In such a case, the employer has penalized a member of one
The Court declines to address whether Bostock’s reasoning reaches beyond the Title VII context—unlike the employment discrimination at issue in Bostock, changing a minor’s sex or transgender status does not alter the application of SB1. If a transgender boy seeks testosterone to treat gender dysphoria, SB1 prevents a healthcare provider from administering it to him. If his biological sex were changed from female to male, SB1 would still not permit him the hormones he seeks because he would lack a qualifying diagnosis. The transgender boy could receive testosterone only if he had a permissible diagnosis (like a congenital defect). And, if he had such a diagnosis, he could obtain the testosterone regardless of his sex or transgender status. Under thе reasoning of Bostock, neither his sex nor his transgender status is the but-for cause of his inability to obtain testosterone. Pp. 18–21.
(b) 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.” FCC v. Beach Communications, Inc., 508 U. S. 307, 313. SB1 clearly meets that standard of review. Tennessee determined that administering puberty blockers or hormones to minors to treat gender dysphoria, gender identity disorder, or gender incongruence carries risks, including irreversible sterility, increased risk of disease and illness, and adverse psychological consequences. The legislature found that minors lack the maturity to fully understand these consequences, that many individuals have expressed regret for undergoing such treatments as minors, and that the full effects of such treatments may not yet be known. At the same time, the State noted evidence that discordance between sex and gender can be resolved through less invasive approaches. SB1’s age- and diagnosis-based classifications are rationally related to these findings and the State’s objective of protecting minors’ health and welfare.
The Court also declines the plaintiffs’ invitation to second-guess the lines that SB1 draws. States have “wide discretion to pass legislation in areas where there is medical and scientific uncertainty.” Gonzales v. Carhart, 550 U. S. 124, 163. Recent developments demonstrate the open questions that exist regarding basic factual issues before medical authorities and regulatory bodies in this area, underscoring the need for legislative flexibility. Pp. 21–24.
(c) 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. The Equal Protection Clause does not resolve
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these disagreements. The Court’s role is not “to judge the wisdom, fairness, or logic” of SB1, Beach Communications, 508 U. S., at 313, but only to ensure that the law does not violate equal protection guarantees. It does not. Questions regarding the law’s policy are thus appropriately left to the people, their elected representatives, and the democratic process. P. 24.
83 F. 4th 460, affirmed.
ROBERTS, C. J., delivered the opinion of the Court, in which THOMAS, GORSUCH, KAVANAUGH, and BARRETT, JJ., joined, and in which ALITO, J., joined as to Parts I and II–B. THOMAS, J., filed a concurring opinion. BARRETT, J., filed a concurring opinion, in which THOMAS, J., joined. ALITO, J., filed an opinion concurring in part and concurring in the judgment. SOTOMAYOR, J., filed a dissenting opinion, in which JACKSON, J.,
UNITED STATES, PETITIONER v. JONATHAN SKRMETTI, ATTORNEY GENERAL AND REPORTER FOR TENNESSEE, ET AL.
No. 23–477
SUPREME COURT OF THE UNITED STATES
June 18, 2025
605 U. S. ____ (2025)
ON WRIT OF CERTIORARI TO THE UNITED STATES COURT OF APPEALS FOR THE SIXTH CIRCUIT
Opinion of the Court
NOTICE: This opinion is subject to formal revision before publication in the United States Reports. Readers are requested to notify the Reporter of Decisions, Supreme Court of the United States, Washington, D. C. 20543, pio@supremecourt.gov, of any typographical or other formal errors.
SUPREME COURT OF THE UNITED STATES
No. 23–477
UNITED STATES, PETITIONER v. JONATHAN SKRMETTI, ATTORNEY GENERAL AND REPORTER FOR TENNESSEE, ET AL.
ON WRIT OF CERTIORARI TO THE UNITED STATES COURT OF APPEALS FOR THE SIXTH CIRCUIT
[June 18, 2025]
CHIEF JUSTICE ROBERTS delivered the opinion of the Court.
In this case, we consider whether a Tennessee law banning certain medical care for transgender minors violates the Equal Protection Clause of the Fourteenth Amendment.
I
A
An estimated 1.6 million Americans over the age of 13 identify as transgender, meaning that their gender identity does not align with their biological sex. See 1 App. 257–259; 2 id., at 827. Some transgender individuals suffer from gender dysphoria, a medical condition characterized by persistent, clinically significant distress resulting from an incongruence between gender identity and biological sex. Left untreated, gender dysphoria may result in severe physical and psychological harms.
In 1979, the World Professional Association for Transgender Health (WPATH) (then known as the Harry Benjamin International Gender Dysphoria Association)
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published one of the first sets of clinical
In 1998, WPATH revised its standards of care to permit healthcare professionals to administer puberty blockers (designed to delay the development of physical sex characteristics) and hormones to minors in “rar[e]” circumstances. S. Levine et al., The Standards of Care for Gender Identity Disorders (5th ed. 1998), reprinted in 11 J. Psychology & Human Sexuality 1, 20 (1999). Today, the standards discuss a range of factors regarding the provision of such treatments to minors. E. Coleman et al., Standards of Care for the Health of Transgender and Gender Diverse People, Version 8, 23 Int’l J. Transgender Health S1, S65–S66 (2022). The current standards recognize known risks associated with the provision of sex transition treatments to adolescents, including potential adverse effects on fertility and the possibility that an adolescent will later wish to detransition. See id., at S47, S57, S61–S62. They further state that there is “limited data on the optimal timing” of sex
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transition treatments or “the long-term physical, psychological, and neurodevelopmental outcomes in youth,” id., at S65, and note that “[o]ur understanding of gender identity development in adolescence is continuing to evolve,” id., at S44.
In recent years, the number of minors requesting sex transition treatments has increased. See 2 App. 644, 827–828. This increase has corresponded with rising debates regarding the relative risks and benefits of such treatments. Compare, e.g., Brief for State of California et al. as Amici Curiae 1–13, with Brief for Alabama as Amicus Curiae 1–9. In the last three years, more than 20 States have enacted laws banning the provision of sex transition treatments to minors, while two have enacted near total bans.
Meanwhile, health authorities in a number of European countries have raised significant concerns regarding the potential harms associated with using puberty blockers and hormones to treat transgender minors. In 2020, Finland’s Council for Choices in Health Care found that “gender reassignment of minors is an experimental practice” and that “the reliability of the existing studies” is “highly uncertain.” 2 App. 583–584 (alterations omitted); see id., at 715–722, 727–729. That same year, England’s National Institute for Health and Care Excellence published reports finding that the evidence for using puberty blockers to treat transgender adolescents is of “very low certainty” and that the long-term risks associated with using hormones to treat adolescents with gender dysphoria are “largely unknown.” Id., at 588–589. In 2022, Sweden’s National Board of Health and Welfare found that “the evidence on treatment efficacy and safety is still insufficient and inconclusive” and that the
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knowledge” for hormonal sex transition treatments for minors is “insufficient,” while the “long-term effects are little known.” 1 id., at 341–342.
B
In March 2023, Tennessee joined the growing number of States restricting sex transition treatments for minors by enacting the Prohibition on Medical Procedures Performed on Minors Related to Sexual Identity, S. B. 1, 113th Gen. Assem., 1st Extra. Sess.;
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be resolved by less invasive approaches that are likely to result in better outcomes.”
SB1 responds to these concerns by banning the use of certain medical procedures for treating transgender minors. In particular, the law prohibits a healthcare provider from “[s]urgically removing, modifying, altering, or entering into tissues, cavities, or organs of a human being,” or “[p]rescribing, administering, or dispensing any puberty blocker or hormone,”
SB1 is limited in two relevant ways. First, SB1 does not restrict the administration of puberty blockers or hormones to individuals 18 and over.
SB1 contains three primary enforcement mechanisms. The law authorizes Tennessee’s attorney general to bring against any person who knowingly violates SB1 an action “to enjoin further violations, to disgorge any profits received due to the medical procedure, and to recover a civil penalty
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of [$25,000] per violation.”
C
Three transgender minors, their parents, and a doctor (plaintiffs) brought a pre-enforcement challenge to SB1. Among other things, the plaintiffs asserted that SB1 violates the Equal Protection Clause of the Fourteenth Amendment. They moved for a preliminary injunction preventing the law’s bans on sex transition treatments for minors from going into effect. The United States intervened under
The District Court partially enjoined enforcement of SB1’s prohibitions. See L. W. v. Skrmetti, 679 F. Supp. 3d 668, 677 (MD Tenn. 2023). The court concluded that the plaintiffs lacked standing to challenge the law’s ban on sex transition surgery for minors. Id., at 681–682. But the court held, as relevant, that the United States and plaintiffs were likely to succeed on their equal protection challenge to the law’s prohibitions on puberty blockers and hormones. Id., at 682–712. The court found that transgender individuals constitute a quasi-suspect class, that SB1 discriminates on the basis of sex and transgender status, and that SB1 was unlikely to survive intermediate scrutiny. Id., at 686–687, 698, 712. Having concluded that SB1 was likely unconstitutional on its face, the District Court issued a
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statewide injunction enjoining enforcement of all provisions of SB1 except for the private right of action and the law’s ban on sex transition surgery. See id., at 680–681, 716–718. Tennessee appealed, and the Sixth Circuit stayed the preliminary injunction pending appeal. L. W. v. Skrmetti, 83 F. 4th 460, 469 (CA6 2023).
The Sixth Circuit reversed. As rеlevant, the Sixth Circuit held that the United States and plaintiffs were unlikely to succeed on the merits of their equal protection claim. See id., at 479–489. The court first found that SB1 does not classify on the basis of sex because the law “regulate[s] sex transition treatments for all minors, regardless of sex,” by prohibiting all minors from “receiv[ing] puberty blockers or hormones or surgery in order to transition from one sex to another.” Id., at 480. The court next declined to recognize transgender individuals as a suspect class, finding that transgender individuals are neither politically powerless nor a discrete group defined by obvious, immutable, or distinguishing characteristics. Id., at 486–487. Finally, the court concluded that the United States and plaintiffs had failed to
Judge White dissented. Judge White would have held that the United States and plaintiffs were likely to succeed on the merits of their equal protection claim. Id., at 498. In her view, SB1 triggered heightened scrutiny because it “facially discriminate[s] based on a minor’s sex as assigned at birth and on a minor’s failure to conform with societal expectations concerning that sex.” Ibid. Judge White would have held that Tennessee had failed to “show an exceed-ingly persuasive justification or close means-ends fit” for
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the law’s sex-based classifications. Ibid.
We granted certiorari to decide whether SB1 violates the Equal Protection Clause of the Fourteenth Amendment.1 602 U. S. ___ (2024).
II
The Fourteenth Amendment’s command that no State shall “deny to any person within its jurisdiction the equal protection of the laws,”
Certain legislative classifications, however, prompt heightened review. For example, laws that classify on the basis of race, alienage, or national origin trigger strict scrutiny and will pass constitutional muster “only if they are suitably tailored to serve a compelling state interest.” Ibid. We have similarly held that sex-based classifications warrant heightened scrutiny. See United States v. Virginia,
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518 U. S. 515, 533 (1996). While our precedent does not make sex a “proscribed classification,” id., we have explained that sex “generally provides no sensible ground for differential treatment,” Cleburne, 473 U. S., at 440, and that sex-based lines too often reflect stereotypes or over-broad generalizations about the differences between men and women, see Sessions v. Morales-Santana, 582 U. S. 47, 62 (2017). We accordingly subject laws containing sex-based classifications to intermediate scrutiny, under which the State must show that the “classification
A
We are asked to decide whether SB1 is subject to heightened scrutiny under the Equal Protection Clause. We hold it is not. SB1 does not classify on any bases that warrant heightened review.
1
On its face, SB1 incorporates two classifications. First, SB1 classifies on the basis of age. Healthcare providers may administer certain medical treatments to individuals ages 18 and older but not to minors. Second, SB1 classifies on the basis of medical use. Healthcare providers may administer puberty blockers or hormones to minors to treat certain conditions but not to treat gender dysphoria, gender identity disorder, or gender incongruence. Classificatiоns that turn on age or medical use are subject to only rational basis review. See Massachusetts Bd. of Retirement v. Murgia, 427 U. S. 307, 312–314 (1976) (per curiam) (rational basis review applies to age-based classification); Vacco v. Quill, 521 U. S. 793, 799–808 (1997) (state laws outlawing assisted suicide “neither infringe fundamental rights nor
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involve suspect classifications”).
The plaintiffs argue that SB1 warrants heightened scrutiny because it relies on sex-based classifications. See Brief for Respondents in Support of Petitioner 20–37. We disagree.
Neither of the above classifications turns on sex. Rather, SB1 prohibits healthcare providers from administering puberty blockers and hormones to minors for certain medical uses, regardless of a minor’s sex. Cf. Vacco, 521 U. S., at 800 (“On their faces, neither New York’s ban on assisting suicide nor its statutes permitting patients to refuse medical treatment treat anyone differently from anyone else or draw any distinctions between persons. Everyone, regardless of physical condition, is entitled, if competent, to refuse unwanted lifesaving medical treatment; no one is permitted to assist a suicide.”).
The plaintiffs resist this conclusion, arguing that SB1 creates facial sex-based classifications by defining the prohibited medical care based on the patient’s sex. See Brief for Respondents in Support of Petitioner 22. This argument takes two forms. At times, the plaintiffs suggest that SB1 classifies on the basis of sex because its prohibitions reference sex. Alternatively, the plaintiffs contend that SB1 works a sex-based classification because application of the law turns on sex. Neither argument is persuasive.
This Court has never suggested that mere reference to sex is sufficient to trigger heightened scrutiny. See, e.g., Tuan Anh Nguyen v. INS, 533 U. S. 53, 64 (2001) (“The issue is not the use of gender specific terms instead of neutral ones. Just as neutral terms can mask discrimination that is unlawful, gender specific terms can mark a permissible distinction.”). Such an approach, moreover, would be especially inappropriate in the medical context. Some medical treatments and procedures are uniquely bound up in sex. The Food and Drug Administration itself recognizes that “[r]esearch has shown that biological differences between
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men and women (differences due to sex chromosome or sex hormones) may contribute to variations seen in the safety and efficacy of drugs, biologics,
We also reject the argument that the application of SB1 turns on sex. The plaintiffs and the dissent contend that an adolescent whose biological sex is female cannot receive puberty blockers or testosterone to live and present as a male, but an adolescent whose biological sex is male can, while an adolescent whose biological sex is male cannot receive puberty blockers or estrogen to live and present as a female, but an adolescent whose biological sex is female can. See Brief for Respondents in Support of Petitioner 22; post, at 10–15 (SOTOMAYOR, J., dissenting). So conceived, they argue, SB1 prohibits certain treatments for minors of one sex while allowing those same treatments for minors of the opposite sex.
The plaintiffs and the dissent, however, contort the meaning of the term “medical treatment.” Notably absent from their framing is a key aspect of any medical treatment: the underlying medical concern the treatment is intended to address. The Food and Drug Administration approves
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drugs and requires that they be labeled for particular indications—the diseases or conditions that they treat, prevent, mitigate, diagnose, or cure. See
When properly understood from the perspective of the indications that puberty blockers and hormones treat, SB1 clearly does not classify on the basis of sex. Both puberty blockers and hormones can be used to treat certain overlapping indications (such as gender dysphoria), and each can be used to treat a range of other conditions. Id., at 6–7. These combinations of drugs and indications give rise to various medical treatments. When, for example, a transgender boy (whose biological sex is female) takes puberty blockers to treat his gender incongruence, he receives a different medical treatment than a boy whose biological sex is male who takes puberty blockers to treat his precocious puberty.2 SB1, in turn, restricts which of these medical treatments are available to minors: Under SB1, a healthcare provider
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Of course, a State may not circumvent the Equal Protection Clause by writing in abstract terms. See Personnel Administrator of Mass. v. Feeney, 442 U. S. 256, 274 (1979) (explaining that both overt and covert sex-based classifications are subject to heightened review). The antimiscegenation law that this Court struck down in Loving v. Virginia, 388 U. S. 1 (1967), would not have shed its race-based classification had it, for example, prohibited “any person from marrying an individual of a different race.” Such a law would still have turned on a race-based classification: It would have prohibited Mildred Jeter (a black woman) from marrying Richard Loving (a white man), while permitting a white woman to do so. The law, in other words, would still “proscribe generally accepted conduct if engaged in by members of different races.” Id., at 11.
Here, however, SB1 does not mask sex-based classifications. For reasons we have explained, the law does not prohibit conduct for one sex that it permits for the other. 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.
Nor are we persuaded that SB1’s prohibition on the prescription of puberty blockers and hormones to “[e]nabl[e] a minor to identify with, or live as, a purported identity inconsistent with the minor’s sex” or to “[t]rea[t] purported discomfort or distress from a discordance between the minor’s sex and asserted identity,”
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this language “plainly classifies on the basis of sex” because it “turns on inconsistency with a protected characteristic.” Post, at 11. The dissent analogizes to a hypothetical law that “prohibit[s] minors from attending any services, rituals, or assemblies if done for the purpose of allowing the minor to identify with a purported identity inconsistent with the minor’s religion.” Ibid. (internal quotation marks omitted; emphasis deleted). Such a law, the dissent argues, would plainly classify on the basis of religion. “Whether the law prohibits a minor from attending any particular religious service turns on the minor’s religion: A Jewish child can visit a synagogue but not a church, while a Christian child can attend church but not the synagogue.” Ibid.
But a prohibition on the prescription of puberty blockers and hormones to “[e]nabl[e] a minor to identify with, or live as, a purported identity inconsistent with the minor’s sex,”
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girls to look and live like boys and girls.” (internal quotation marks omitted)).
To start, the plaintiffs’ allegations of sex stereotyping are misplaced. True, a law that classifies on the basis of sex may fail heightened scrutiny if the classifications rest on impermissible stereotypes. See J. E. B. v. Alabama ex rel. T. B., 511 U. S. 127, 139, n. 11 (1994). But where a law’s classifications are neither covertly nor overtly based on sex, contrast, e.g., post, at 12–13, n. 8 (opinion of SOTOMAYOR, J.) (referencing a hypothetical requirement that all children wear “sex-consistent clothing”), we do not subject the law to heightened review unless it was motivated by an invidious discriminatory purpose, see Personnel Administrator of Mass., 442 U. S., at 271–274; Arlington Heights v. Metropolitan Housing Development Corp., 429 U. S. 252, 264–266 (1977). No such argument has been raised here. See Tr. of Oral Arg. 57–59.
Regardless, the statutory findings to which the plaintiffs point do not themselves evince sex-based stereotyping. The plaintiffs fail to note that Tennessee also proclaimed a “legitimate, substantial, and compelling interest in protecting minors from physical and emotional harm.”
was not improper to conclude that kids benefit from additional time to “appreciate their sex” before embarking on body-altering paths. Nor is it improper for the State to protect minors from procedures that “encourage them to become disdainful of their sex“—and thus at risk for serious psychiatric conditions.” (citations and alterations omitted)); L. W., 83 F. 4th, at 485 (“A concern about potentially irreversible medical procedures for a child is not a form of stereotyping.“).
2
The plaintiffs separately argue that SB1 warrants heightened scrutiny because it discriminates against transgender individuals, who the plaintiffs assert constitute a quasi-suspect class. See Brief for Respondents in Support of Petitioner 37–38. This Court has not previously held that transgender individuals are a suspect or quasi-suspect class. And this case, in any event, does not raise that question because
We have explained that a State does not trigger heightened constitutional scrutiny by regulating a medical procedure that only one sex can undergo unless the regulation is a mere pretext for invidious sex discrimination. In Geduldig v. Aiello, 417 U.S. 484 (1974), for example, we held that a California insurance program that excluded from coverage certain disabilities resulting from pregnancy did not discriminate on the basis of sex. See id., at 486, 492–497. In reaching that holding, we explained that the program did not exclude any individual from benefit eligibility because of the individual‘s sex but rather “remove[d] one physical condition—pregnancy—from the list of compensable disabilities.” Id., at 496, n. 20. We observed that the “lack of identity” between sex and the excluded pregnancy-related disabilities became “clear upon the most cursory analysis.” Id., at 497, n. 20. The California insurance program, we explained, divided potential recipients into two groups: “pregnant women and nonpregnant persons.” Ibid. Because women fell into both groups, the program did not discriminate against women as a class. See id., at 496, and n. 20. We thus concluded that, even though only biological women can become pregnant, not every legislative classification concerning pregnancy is a sex-based classification. Id., at 496, n. 20. As such, “[a]bsent a showing that distinctions involving pregnancy are mere pretexts designed to effect an invidious discrimination against the members of one sex or the other, lawmakers are constitutionally free to include or exclude pregnancy from the coverage of legislation . . . on any reasonable basis, just as with respect to any other physical condition.” Id., at 496–497, n. 20.
By the same token, SB1 does not exclude any individual from medical treatments on the basis of transgender status but rather removes one set of diagnoses—gender dysphoria, gender identity disorder, and gender incongruence—from the range of treatable conditions. SB1 divides minors into two groups: those who might seek puberty blockers or hormones to treat the excluded diagnoses, and those who might seek puberty blockers or hormones to treat other conditions. See
3
Finally, Bostock v. Clayton County, 590 U.S. 644 (2020), does not alter our analysis. In Bostock, we held that an employer who fires an employee for being gay or transgender violates
The plaintiffs urge us to apply Bostock‘s reasoning to this case. In their view, SB1 violates the Equal Protection Clause because it prohibits a minor whose biological sex is female from receiving testosterone to live as a male but allows a minor whose biological sex is male to receive testosterone for the same purposes (and vice versa). Applying Bostock‘s reasoning, they argue that SB1 discriminates on the basis of sex because it intentionally penalizes members of one sex for traits and actions that it tolerates in another. See Brief for Respondents in Support of Petitioner 24–25.
We have not yet considered whether Bostock‘s reasoning reaches beyond the
The dissent counters that, whatever causal factors are at play, sex is at least one but-for cause of SB1‘s operation. See post, at 19–20 (opinion of SOTOMAYOR, J.). To illustrate this argument, the dissent posits a minor girl with facial hair inconsistent with her sex. Under SB1, the
The dissent‘s reasoning overlooks a key distinction between the operation of SB1 and the logic of Bostock. Under Bostock‘s reasoning, an employer who fires a homosexual male employee for being attracted to men while retaining the employee‘s straight female colleague has discriminated on the basis of sex because it has penalized the male employee for a trait (attraction to men) that it tolerates in the female employee. See id., at 660. Bostock held that, in such a circumstance, sex is the but-for cause of the employer‘s decision—change the homosexual male employee‘s sex and he becomes a straight female whose attraction to men the employer tolerates.
Not so with SB1. Consider again the minor girl with unwanted facial hair inconsistent with her sex. If she has a diagnosis of hirsutism (male-pattern hair growth), a healthcare provider may, consistent with SB1, prescribe her puberty blockers or hormones. But changing the minor‘s sex to male does not automatically change the operation of SB1. If hirsutism is replaced with gender dysphoria, the now-male minor may not receive puberty blockers or hormones; but if hirsutism is replaced with precocious puberty, SB1 does not bar either treatment. Unlike the homosexual male employee whose sexuality automatically switches to straight when his sex is changed from male to female, there is no reason why a female minor‘s diagnosis of hirsutism automatically changes to gender dysphoria when her sex is changed from female to male. Under the logic of Bostock, then, sex is simply not a but-for cause of SB1‘s operation.
B
The rational basis inquiry “employs a relatively relaxed standard reflecting the Court‘s awareness that the drawing of lines that create distinctions is peculiarly a legislative task and an unavoidable one.” Massachusetts Bd. of Retirement, 427 U.S., at 314. Under this standard, we 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.” FCC v. Beach Communications, Inc., 508 U.S. 307, 313 (1993). Where there exist “plausible reasons” for the relevant government action, “our inquiry is at an end.” Id., at 313–314 (internal quotation marks omitted).
SB1 clearly meets this standard. Tennessee determined that administering puberty blockers or hormones to a minor to treat gender dysphoria, gender identity disorder, or gender incongruence “can lead to the minor becoming irreversibly sterile, having increased risk of disease and illness, or suffering from adverse and sometimes fatal psychological consequences.”
The plaintiffs argue that SB1 fails even rational basis review because the law‘s classifications are “so far removed from [Tennessee‘s] asserted justifications that it is impossible to credit those interests.” Brief for Respondents in Support of Petitioner 51 (internal quotation marks and alterations omitted). In their view, Tennessee has failed to explain why it has banned access to puberty blockers and hormones ”only where they would allow a transgender minor to ‘identify’ or ‘live’ in a way ‘inconsistent’ with their ‘sex.‘” Id., at 52.
This argument fails. As we have explained, there is a rational basis for SB1‘s classifications. Tennessee concluded that there is an ongoing debate among medical experts regarding the risks and benefits associated with administering puberty blockers and hormones to treat gender dysphoria, gender identity disorder, and gender incongruence. SB1‘s ban on such treatments responds directly to that uncertainty. Contrast Cleburne, 473 U.S., at 448 (record did not reveal “any rational basis” for city zoning ordinance); Romer, 517 U.S., at 632 (“sheer breadth” of law was “so discontinuous with the reasons offered for it that the [law] seem[ed] inexplicable by anything but animus toward the class it affect[ed]“).
We also decline the plaintiffs’ invitation to second-guess the lines that SB1 draws. It may be true, as the plaintiffs contend, that puberty blockers and hormones carry comparable risks for minors no matter the purposes for which they are administered. But it may also be true, as Tennessee determined, that those drugs carry greater risks when administered to treat gender dysphoria, gender identity disorder, and gender incongruence. We afford States “wide discretion to pass legislation in areas where there is medical and scientific uncertainty.” Gonzales v. Carhart, 550 U. S. 124, 163 (2007). “[T]he fact the line might have been drawn differently at some points is a matter for legislative, rather than judicial, consideration.” Railroad Retirement Bd. v. Fritz, 449 U.S. 166, 179 (1980); see Dandridge v. Williams, 397 U.S. 471, 485 (1970) (“In the area of economics and social welfare, a State does not violate the Equal Protection Clause merely because the classifications made by its laws are imperfect.“); Lindsley v. Natural Carbonic Gas Co., 220 U.S. 61, 78 (1911) (“A classification having some reasonable basis does not offend against [the Equal Protection Clause] merely because it is not made with mathematical nicety or because in practice it results in some inequality.“).
Recent developments only underscore the need for legislative flexibility in this area. After Tennessee enacted SB1, a report commissioned by England‘s National Health Service (NHS England) characterized the evidence concerning the use of puberty blockers and hormones to treat transgender minors as “remarkably weak,” concluding that there is “no good evidence
We cite this report and NHS England‘s response not for guidance they might provide on the ultimate question of United States law, see Schriro v. Summerlin, 542 U.S. 348, 356 (2004) (contemporary foreign practice is “irrelevant” to constitutional interpretation), but to demonstrate the open questions regarding basic factual issues before medical authorities and other regulatory bodies. Such uncertainty “afford[s] little basis for judicial responses in absolute terms.” Marshall v. United States, 414 U.S. 417, 427 (1974). And “[t]he calculus of effects, the manner in which a particular law reverberates in a society, is a legislative and not a judicial responsibility.” Personnel Administrator of Mass. v. Feeney, 442 U.S. 256, 272 (1979).
* * *
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. 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. Our role is not “to judge the wisdom, fairness, or logic” of the law before us, Beach Communications, 508 U.S., at 313, but only to ensure that it does not violate the equal protection guarantee of the
The judgment of the United States Court of Appeals for the Sixth Circuit is affirmed.
It is so ordered.
UNITED STATES, PETITIONER v. JONATHAN SKRMETTI, ATTORNEY GENERAL AND REPORTER FOR TENNESSEE, ET AL.
No. 23–477
SUPREME COURT OF THE UNITED STATES
[June 18, 2025]
605 U. S. ____ (2025)
THOMAS, J., concurring
JUSTICE THOMAS, concurring.
A Tennessee law prevents children from receiving certain medical interventions if administered to treat gender dysphoria. See Prohibition on Medical Procedures Performed on Minors Related to Sexual Identity, S. B. 1, 113th Gen. Assem., 1st Extra. Sess.;
I
Before this Court, the United States and the private plaintiffs asserted that, under
While I continue to think that the Bostock majority‘s logic “fails on its own terms,” see 590 U.S., at 689–699 (ALITO, J., dissenting), I see in any event no reason to import Bostock‘s
The Equal Protection Clause includes none of this language. See
Extending the Bostock framework here would depart dramatically from this Court‘s Equal Protection Clause jurisprudence. We have faced sexual-orientation claims in the equal protection context for decades. See, e.g., Obergefell v. Hodges, 576 U.S. 644 (2015); United States v. Windsor, 570 U.S. 744 (2013); Romer v. Evans, 517 U.S. 620 (1996). “But in those cases, the Court never suggested that sexual orientation discrimination is just a form of sex discrimination” warranting heightened constitutional scrutiny. Bostock, 590 U.S., at 797 (KAVANAUGH, J., dissenting). For example, while pregnancy is undeniably “bound up with sex,” id., at 661 (majority opinion), the Court has rejected
Applying Bostock‘s reasoning to the Equal Protection Clause would also invite sweeping consequences. Many statutes “regulate medical procedures defined by sex.” L. W. v. Skrmetti, 83 F. 4th 460, 482 (CA6 2023) (collecting examples, including laws referencing testicular and prostate cancer). If heightened scrutiny applied to such laws, then “[a]ny person with standing to challenge” such a decision could “haul the State into federal court and compel it to establish by evidence (presumably in the form of expert testimony) that there is an ‘exceedingly persuasive justification’ for the classification.” United States v. Virginia, 518 U.S. 515, 597 (1996) (Scalia, J., dissenting). Given the ensuing potential for “high-cost, high-risk lawsuit[s],” ibid., States might simply decline to adopt or enforce sex-based medical laws or regulations, even where such rules would be best medical practice. The burden of skeptical judicial review is therefore far from the “modest step” of requiring a State to “show its work” that the dissent posits. Post, at 31 (opinion of SOTOMAYOR, J.).3
And, if Bostock‘s reasoning applies to sex, it is difficult to see why it would not apply to other protected characteristics. Race presumably would be a but-for cause of—or, at least, “inextricably bound up with,” 590 U. S., at 660–661—a university‘s decision to credit “an applicant‘s discussion of how race affected his or her life,” Students for Fair Admissions, Inc., 600 U.S., at 230. Under Bostock‘s reasoning, such an essay is permissible only if it can survive our “daunting” strict-scrutiny standard. 600 U.S., at 206; but see, e.g., Washington v. Davis, 426 U.S. 229, 239 (1976) (noting that the Court has “never held that the constitutional standard for adjudicating claims of invidious racial discrimination is identical to the standards applicable under Title VII“).
The Constitution compels none of this. While the majority concludes that SB1 does not discriminate based on sex even under Bostock‘s incorrect reasoning, see ante, at 18–19, I would make clear that, in constitutional challenges, courts need not engage Bostock at all.
II
The Court rightly rejects efforts by the United States and the private plaintiffs to accord outsized credit to claims about medical consensus and expertise. The United States asserted that “the medical community
There are several problems with appealing and deferring to the authority of the expert class. First, so-called experts have no license to countermand the “wisdom, fairness, or logic of legislative choices.” FCC v. Beach Communications, Inc., 508 U.S. 307, 313 (1993). Second, contrary to the representations of the United States and the private plaintiffs, there is no medical consensus on how best to treat gender dysphoria in children. Third, notwithstanding the alleged experts’ view that young children can provide informed consent to irreversible sex-transition treatments, whether such consent is possible is a question of medical ethics that States must decide for themselves. Fourth, there are particularly good reasons to question the expert class here, as recent revelations suggest that leading voices in this area have relied on questionable evidence, and have allowed ideology to influence their medical guidance.
Taken together, this case serves as a useful reminder that the American people and their representatives are en-titled to disagree with those who hold themselves out as experts, and that courts may not “sit as a super-legislature to weigh the wisdom of legislation.” Day-Brite Lighting, Inc. v. Missouri, 342 U.S. 421, 423 (1952). By correctly concluding that SB1 warrants the “paradigm of judicial restraint,” Beach Communications, 508 U.S., at 314, the Court reserves to the people of Tennessee the right to decide for themselves.
A
The views of self-proclaimed experts do not “shed light on the meaning of the Constitution.” Dobbs, 597 U.S., at 272–273. Thus, whether “major medical organizations” agree with the result of Tennessee‘s democratic process is irrelevant. Post, at 5, n. 5 (opinion of SOTOMAYOR, J.). To hold otherwise would permit elite sentiment to distort and stifle democratic debate under the guise of scientific judgment, and would reduce judges to mere “spectators . . . in construing our Constitution.” 83 F. 4th, at 479.
Just a few Terms ago, this Court acknowledged the importance of reserving to the democratic process the right to decide controversial medical questions. In Dobbs, the respondents sought to invoke the authority of “overwhelming medical consensus” and “numerous major medical organizations” to dispatch with Mississippi‘s asserted interest in minimizing pain for the unborn. Brief for Respondents, O. T. 2021, No. 19–1932, pp. 31–32. The Court pointedly rejected the notion that a consensus among popular expert groups could remove “the mitigation of fetal pain” from the “legitimate interests” of the people. 597 U.S., at 301.
Rational-basis review is critical to safeguarding these legitimate interests. Under this level of review, courts ask only whether a law is “rationally related to a legitimate governmental interest.” Department of Agriculture v. Moreno, 413 U.S. 528, 533 (1973). That deferential standard is not only legally compelled in this case, but is practically essential for preserving “the original constitutional proposition that courts do not substitute their social and economic beliefs
B
Before this Court, the United States asserted that “overwhelming evidence” supports the use of puberty blockers and cross-sex hormones for treating pediatric gender dysphoria, and that this view represents “the overwhelming consensus of the medical community.” Pet. for Cert. 2, 7. These claims are untenable. “[T]he concept of gender dysphoria as a medical condition is relatively new and the use of drug treatments that change or modify a child‘s sex characteristics is even more recent.” 83 F. 4th, at 472. The treatments at issue are subject to a rapidly evolving debate that demonstrates a lack of medical consensus over their risks and benefits. Under these conditions, it is imperative that courts treat state legislation with “a strong presumption of validity,” Beach Communications, 508 U.S., at 314, and in turn protect States’ ability to enact “high-stakes medical policies, in which compassion for the child points in both directions,” 83 F. 4th, at 472.
1
SB1 prohibits puberty blockers, cross-sex hormones, and surgery for the purpose of treating gender dysphoria in children. See
Puberty Blockers. Puberty blockers are powerful synthetic drugs “designed to slow the development of male and female physical features.” 83 F. 4th, at 467. The Food and Drug Administration (FDA) initially approved these drugs “to treat prostate cancer; endometriosis, a painful disease that causes uterine tissue to grow elsewhere in the body; and the unusually early onset of puberty,” also known as “precocious puberty.” M. Twohey & C. Jewett, Pressing Pause on Puberty, N. Y. Times, Nov. 14, 2022, pp. A14–A15 (Twohey 2022).
For purposes of treating gender dysphoria, however, puberty blockers generally are administered “off-label,” meaning without FDA authorization for the specific use. See 2 App. 838–839; 83 F. 4th, at 478. Although it is neither unusual nor unlawful for drugs to be used off-label, the FDA has recognized that “just because a drug has been approved for one class of patients doesn‘t mean it‘s safe for another.” Twohey 2022, at A15. That admonition is important here: To treat precocious puberty, puberty blockers are administered until
This absence of evidence is a “major drawback” in assessing the effects of puberty blockers on children with gender dysphoria. G. Betsi, P. Goulia, S. Sandhu, & P. Xekouki, Puberty Suppression in Adolescents With Gender Dysphoria: An Emerging Issue With Multiple Implications, Frontiers in Endocrinology 16 (2024). “The existing studies are limited in number, of small sample size, uncontrolled, observational, usually short-term, [and] potentially subject to bias.” Ibid.; see also, e.g., C. Terhune, R. Respaut, & M. Conlin, As More Transgender Children Seek Medical Care, Families Confront Many Unknowns, Reuters (Oct. 6, 2022), https://www.reuters.com/investigates/special-report/usa-transyouth-care (“No clinical trials have established [puberty blockers‘] safety for such off-label use“).
It is undisputed, however, that these treatments carry risks. Research suggests that, aside from interrupting a child‘s normal pubertal development, puberty blockers may lead to decreased bone density and impacts on brain development. See, e.g., 2 App. 678–680; M. Cretella, Gender Dysphoria in Children, 32 Issues in L. & Med. 287, 297 (2017). And, “[d]espite widespread assertions that puberty blockers are ‘fully reversible,‘” it is unclear whether “patients ever develop normal levels of fertility if puberty blockers are terminated after a ‘prolonged delay of puberty.‘” 2 App. 678. At bottom, “[t]here remains considerable uncertainty regarding the effects of puberty blockers in individuals experiencing” gender dysphoria. A. Miroshnychenko et al., Puberty Blockers for Gender Dysphoria in Youth: A Systematic Review and Meta-Analysis, Online First, Archives of Disease in Childhood (Jan. 24, 2025) (draft, at 1), https://adc.bmj.com/content/110/6/429.4
Cross-sex hormones. Following puberty blockers, the next stage of sex-transition treatments for children involves cross-sex hormones. This treatment is also typically “off-label,” 2 App. 780, and requires “very high doses” of hormones of the opposite sex, id., at 769. For example, one of the organizations that sets standards for pediatric sex-transition treatment recommends raising transitioning females’ levels of testosterone “6 to 100 times higher than native female testosterone levels.” Id., at 774. For males seeking to transition into females, the organization recommends raising levels of estradiol, a type of estrogen, to “2 to 43 times above the normal range.” Id., at 780.
Prescribing such high doses of testosterone to girls induces “hyperandrogenism,” which can cause increased cardiovascular risk, “irreversible changes to the vocal cords,” “clitoromegaly and atrophy of the lining of the uterus and vagina,” as well as “ovarian and breast cancer.” Id., at 772–779. Giving high doses of estrogen to boys induces “hyperestrogenemia,” which can produce similarly severe side effects including, among other things, increased cardiovascular risk, breast cancer, and sexual
Surgery. SB1 also bans “[s]urgically removing, modifying, altering, or entering into tissues, cavities, or organs” as a treatment for gender dysphoria.
Sex-transitioning surgeries for girls include “the surgical removal of the breasts” and “phalloplasty,” that is, an “attemp[t] to create a pseudo-penis” by transplanting “a roll of skin and subcutaneous tissue” from another area of the body “to the pelvis.” 2 App. 784–785; see also Lange v. Houston Cty., 101 F. 4th 793, 802 (CA11) (Brasher, J., dissenting) (“[A] natal woman‘s phalloplasty ‘involves removal of the uterus, ovaries, and vagina, and creation of a neophallu[s] and scrotum with scrotal prostheses,’ which ‘is a multistage rеconstructive procedure‘“), vacated and reh‘g en banc granted, 110 F. 4th 1254 (CA11 2024). For boys, surgical interventions include “removal of the testicles alone to permanently lower testosterone levels,” as well as an “attempt to create a pseudo-vagina” by “surgically open[ing]” the boy‘s penis, removing “erectile tissue,” and then “clos[ing] and invert[ing the penis] into a newly created cavity in order to simulate a vagina.” 2 App. 784. These surgical interventions are irreversible, entail significant complications, and, in some cases, result in permanent infertility. Id., at 782–786; see also ES Guidelines 3893.
2
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. 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. Accord, e.g., Beach Communications, 508 U. S., at 314.
The treatments now referred to as “gender-affirming care” were “not available for minors until just before the millennium.” 83 F. 4th, at 467. These treatments originated with Dutch healthcare workers in the 1990s, who first “began using puberty blockers . . . to treat gender dysphoria in minors.” Ibid. The so-called “Dutch Protocol” “permitted puberty blockers for minors during the early stages of puberty, allowed hormone therapy at 16, and allowed genital surgery at 18.” Ibid. (internal quotation marks omitted).
In 1998, the World Professional Association for Transgender Health (WPATH)—which is regarded by some as “the leading association of medical professionals treating transgender individuals,” Brief for United States 3—revised its treatment standards to “endorse the Dutch Protocol.” 83 F. 4th, at 467. Originally, WPATH‘s
At the same time, the number of children identifying as transgender has surged, and medical professionals have increasingly expressed doubts over the quality of evidence supporting the use of puberty blockers, cross-sex hormones, and surgery to treat them. See ante, at 3. Over the past several years, public health authorities in different countries have concluded that these sex-transition treatments are experimental in practice, and that the evidence supporting their use is of “‘very low certainty,‘” “‘insufficient,‘” and “‘inconclusive.‘” Ibid. “In countries like Sweden, Norway, France, the Netherlands and Britain—long considered exemplars of gender progress—medical professionals have recognized that early research on medical interventions for childhood gender dysphoria was either faulty or incomplete.” P. Paul, Gender Dysphoric Kids Deserve Better Care, N. Y. Times, Feb. 4, 2024, p. 9 (Paul 2024); accord,
The Cass Review, published in April 2024, offers an influential example of the
This shifting scientific landscape has forced governments to act quickly under conditions of uncertainty. In the months following the Cass Review‘s publication, for example, NHS imposed new restrictions on the use of puberty blockers and cross-sex hormones for sex-transition treatments. See ante, at 23. And, just a week after oral argument in this case, the United Kingdom indefinitely banned new prescriptions of puberty blockers to treat children with gender dysphoria, except in clinical trials. See S. Castle, Ban on Puberty Blockers for U. K. Teens Is Settled, N. Y. Times Int‘l, Dec. 13, 2024, p. A11. In areas with this much “medical and scientific uncertainty,” courts must afford States “wide discretion.” Gonzales v. Carhart, 550 U. S. 124, 163 (2007).
C
Setting aside whether sex-transition treatments for children are effective, States may legitimately question whether they are ethical. States have a legitimate interest “in protecting the integrity and ethics of the medical profession.” Washington v. Glucksberg, 521 U. S. 702, 731 (1997). And, as the United States has acknowledged, “the ‘general ethical principles’ governing pediatric care” require the patient‘s informed consent. Brief for United States 5. Mounting evidence gives States reason to question whether children are capable of providing informed consent to irreversible sex-transition treatments, and thus whether these treatments can be ethically administered.
1
States could reasonably conclude that the level of young children‘s cognitive and emotional development inhibits their ability to consent to sex-transition treatments. Consistent with WPATH‘s recommendation that puberty blockers be available from the onset of puberty, see WPATH 2022 Guidelines S111, S256, “[m]any physicians in the United States and elsewhere” now “prescrib[e] blockers to patients at the first stage of puberty—as early as age 8.” Twohey 2022, at A14.
But, these are precisely the risks to which children who receive these treatments are required to consent. Consider the contents of a consent form obtained from a gender clinic in Alabama. After providing a long list of potential risks and side effects, many of which are discussed above, see supra, at 7–10, the form requires both the child and parent to initial their consent to various statements. Among these are acknowledgments that “the side effects and safety of these medicines are not completely known,” that the proposed treatment “may affect my sex life in different ways and future ability to cause a pregnancy,” and that the treatments may lead to permanent infertility. See Boe, ECF Doc. 78–41, pp. 3–4, 10. The capacity to knowingly consent to these medical interventions requires a level of comprehension abоut science, sex, and fertility that state legislatures could determine a child is unlikely to possess. See 2 App. 893–895;
2
The voices of “detransitioners“—individuals who have undergone sex-transition treatments but no longer view themselves as transgender—provide States with an additional reason to question whether children are providing informed consent to the medical interventions described above. See, e.g., Brief for Larger Detransitioners Community as Amici Curiae 24–28; Brief for Partners for Ethical Care et al. as Amici Curiae 17–38.
A recurring theme in discussions of detransitioners is that doctors have responded to the “skyrocketing” “number of adolescents requesting [sex-transitioning] medical care” by “hastily dispensing medicine or recommending medical doctors prescribe it.” L. Edwards-Leeper & E. Anderson, The Mental Health Establishment Is Failing Trans Kids, Washington Post, Nov. 24, 2021, pp. B1–B2. In many cases, evidence suggests that children “are being rushed toward” medical treatment “[w]ithout proper assessment,” and “the rising number of detransitioners that clinicians
States have an interest in ensuring that minor patients have the time and capacity to fully understand the irreversible treatments they may undergo. Cf. Gonzales, 550 U. S., at 159 (identifying State‘s “legitimate concern” regarding “lack of information” provided by abortionists). And, despite the supposed expert consensus that young children can consent to irreversible sex-transition treatments, States have good reasons to disagree; as “any parent knows,” children‘s comprehension is limited, Roper, 543 U. S., at 569, and the growing number of detransitioners illustrates the risks of assuming otherwise.
D
Recent revelations suggest that WPATH, long considered a standard bearer in treating pediatric gender dysphoria, see Brief for United States 3, bases its guidance on insufficient evidence and allows politics to influence its medical conclusions. Beyond the lack of consensus over the efficacy and ethics of pediatric sex-transition treatments, these developments provide States even stronger bases for treating supposed authorities in this area with skepticism.
WPATH itself recognizes that evidence supporting the efficacy of puberty blockers, cross-sex hormones, and surgical intervention for treating gender dysphoria in children is lacking. In its most recent Guidelines, for example, the group notes that “[a] key challenge in adolescent transgender care is the quality of evidence evaluating the effectiveness of medically necessary gender-affirming medical and surgical treatments . . . over time.” WPATH 2022 Guidelines S45–S46 (emphasis added). A contributor to the Guidelines underscored this challenge, explaining that, “‘[o]ur concerns, echoed by the social justice lawyers we spoke with, is that evidence-based review reveals little or no evidence and puts us in an untenable position in terms of affecting policy or winning lawsuits.‘” Eknes-Tucker, 114 F. 4th, at 1261 (opinion of Lagoa, J.).
Nevertheless, WPATH publicly represents that “[g]ender-affirming interventions
States would also have good reason to question whether WPATH has a basis for believing that children can provide informed consent to sex-transition treatments. “[I]n a leaked recording of a WPATH Panel,” for example, an endocrinologist acknowledged the difficulty of explaining cross-sex hormones and puberty blockers to children, noting that “‘the thing you have to remember about kids is that we‘re often explaining these sorts of things to people who haven‘t even had biology in high school yet.‘” Eknes-Tucker, 114 F. 4th, at 1268–1269 (opinion of Lagoa, J.). “‘[I]t‘s always a good theory that you talk about fertility preservation with a 14 year old,‘” the endocrinologist continued, “‘but I know I‘m talking to a blank wall.‘” Id., at 1269. Analogizing a teenage patient‘s comprehension to that of a blank wall should raise serious concerns regarding the patient‘s ability to provide informed consent. Given WPATH‘s recognition that “[c]onsent requires the cognitive capacity to understand the risks and benefits of a treat-ment,” Guidelines S38, States thus might reasonably question whether WPATH could be “genuine in its claim that these treatments are safe, effective, and well understood, particularly for minors,” Eknes-Tucker, 114 F. 4th, at 1268 (opinion of Lagoa, J.).
Other “recent revelations” might reinforce the conclusion that “WPATH‘s lodestar is ideology, not science.” Id., at 1261. For example, newly released documents suggest that WPATH tailored its Standards of Care in part to achieve legal and political objectives. In one instance, the chair of WPATH‘s guidelines committee testified that it was “ethically justifiable” for the authors of the WPATH 2022 Guidelines to “advocate for language changes [in these Guidelines] to strengthen [their] position in court.” Boe, ECF Doc. 700–3, p. 42. One of the Guidelines’ contributors was more direct: “My hope with these [Guidelines] is that they land in such a way as to have serious effect in . . . law and policy settings.” ECF Doc. 700–13, p. 25; see also Brief for State of Alabama as Amici Curiae 11–15 (Alabama Brief ) (describing similar statements from other WPATH contributors).
Worse, recent reporting has exposed that WPATH changed its medical guidance to accommodate external political pressure. See Brief for Respondents 9–11; Alabama Brief 15–23. Unsealed documents reveal that a senior official in the Biden administration “pressed [WPATH] to remove age limits for adolescent surgeries from guidelines for care of transgender
Over a decade ago, one of WPATH‘s contributors explained that “‘WPATH aspires to be both a scientific organization and an advocacy group for the transgendered,‘” and admitted that WPATH‘s Standards of Care “‘is not a politically neutral document.‘” Kosilek v. Spencer, 774 F. 3d 63, 78 (CA1 2014). WPATH‘s apparent willingness to let political interests influence its medical conclusions highlights this reality. States are never required to substitute expert opinion for their legislative judgment, and, when the experts appear to have compromised their credibility, it makes good sense to chart a different course.9
* * *
This case carries a simple lesson: In politically contentious debates over matters shrouded in scientific uncertainty, courts should not assume that self-described experts are correct.
Deference to legislatures, not experts, is particularly critical here. Many prominent medical professionals have declared a consensus around the efficacy of treating children‘s gender dysphoriа with puberty blockers, cross-sex hor-mones, and surgical interventions, despite mounting evidence to the contrary. They have dismissed grave problems undercutting the assumption that young children can consent to irreversible treatments that may deprive them of their ability to eventually produce children of their own. They have built their medical determinations on concededly weak evidence. And, they have surreptitiously compromised their medical recommendations to achieve political ends.
The Court today reserves “to the people, their elected representatives, and the democratic process” the power to decide how best to address an area of medical uncertainty and extraordinary importance. Ante, at 24. That sovereign prerogative does not bow to “major medical organizations.” Post, at 5, n. 5 (opinion of SOTOMAYOR, J.). “[E]xperts and elites have been wrong before—and they may prove to be wrong again.” Students for Fair Admissions, Inc. v. President and Fellows of Harvard College, 600 U. S. 181, 268 (2023) (THOMAS, J., concurring).
UNITED STATES, PETITIONER v. JONATHAN SKRMETTI, ATTORNEY GENERAL AND REPORTER FOR TENNESSEE, ET AL.
No. 23–477
SUPREME COURT OF THE UNITED STATES
[June 18, 2025]
605 U. S. ____ (2025)
BARRETT, J., concurring
JUSTICE BARRETT, with whom JUSTICE THOMAS joins, concurring.