SCOTUS Allows For Trans Discrimination In Medical Care: A Full Analysis Of Today's Ruling

Today, SCOTUS released its ruling on Skrmetti, allowing Tennessee to ban transgender healthcare. The ruling was both devastating and limited, leaving many fights unsettled.

Photo by Ian Hutchinson on Unsplash

Today, the Supreme Court issued a devastating 6-3 ruling in United States v. Skrmetti, upholding Tennessee’s ban on gender-affirming care for minors and delivering a major blow to transgender rights. The case raised foundational constitutional questions: whether transgender people constitute a class triggering higher constitutional scrutiny, whether laws targeting them violate equal protection, and whether the Constitution guarantees their right to access medically necessary treatment. The Court sidestepped nearly all of those questions, instead issuing a narrower opinion that carves out an exception permitting medical discrimination based on “gender dysphoria”—a distinction it bizarrely treats as separate from discrimination against transgender people. The ruling effectively greenlights medical care bans across the country and may pave the way for broader restrictions, including for adults, while leaving lower court rulings on bathrooms, schools, sports, and employment remain intact—for now.

In its ruling, the majority opinion of the Supreme Court states that it does not need to address whether or not discrimination against transgender people is sex discrimination because the Tennessee law banning gender affirming healthcare for trans youth is based on “gender dysphoria.” Similarly, the majority argues that it does not have to address whether or not transgender people represent a class that triggers heightened scrutiny, a higher level of scrutiny for constitutional review that has resulted in anti-trans laws being struck down by lower courts. The court states in its majority opinion:

“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… 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.”

In issuing such a ruling, the Court asserts that discrimination based on “gender dysphoria” is somehow distinct from discrimination on the basis of transgender status or sex—creating a loophole wide enough to drive a truck through. In her dissent, Justice Sotomayor calls out the contradiction directly, noting the majority’s logic would permit states to target transgender people while avoiding constitutional scrutiny simply by reframing the language of their laws:

“In addition to discriminating against transgender adolescents, who by definition ‘identify with’ an identity “inconsistent” with their sex, that law conditions the availability of medications on a patient’s sex. Male (but not female) adolescents can receive medicines that help them look like boys, and female (but not male) adolescents can receive medicines that help them look like girls.

Tennessee’s law expressly classifies on the basis of sex and transgender status, so the Constitution and settled precedent require the Court to subject it to intermediate scrutiny. The majority contorts logic and precedent to say otherwise, inexplicably declaring it must uphold Tennessee’s categorical ban on lifesaving medical treatment so long as “‘any reasonably conceivable state of facts’” might justify it. Ante, at 21. Thus, the majority subjects a law that plainly discriminates on the basis of sex to mere rational-basis review. By retreating from meaningful judicial review exactly where it matters most, the Court abandons transgender children and their families to political whims. In sadness, I dissent.”

The Tennessee law, Justice Sotomayor and the dissent argue, explicitly classifies on the basis of sex—so overtly that the majority’s attempt to sidestep that reality reads as disingenuous. The statute itself declares that one purpose of the ban is to “encourage minors to appreciate their sex,” and yet the majority still concludes it does not constitute sex-based classification. Sotomayor dismantles that claim with precision in her dissent, exposing the logical inconsistency at the heart of the Court’s reasoning:

“Consider the mother who contacts a Tennessee doctor, concerned that her adolescent child has begun growing unwanted facial hair. This hair growth, the mother reports, has spurred significant distress because it makes her child look unduly masculine. The doctor’s next step depends on the adolescent’s sex. If the patient was identified as female at birth, SB1 allows the physician to alleviate her distress with testosterone suppressants. See App. to Pet. for Cert. 266a (describing such treatments); App. 100 (same). What if the adolescent was identified male at birth, however? SB1 precludes the patient from receiving the same medicine.”

One of the more strained justifications in the majority opinion mirrors arguments once used to deny rights to same-sex and interracial couples: that the law does not discriminate against transgender people, but instead bars both cisgender and transgender people from receiving medication to treat gender dysphoria. It's a tortured rationale—functionally absurd given that transgender people will need the medical treatment for gender dysphoria, not cisgender people.

Sotomayor compares this rationale to that used in Loving v. Virginia, a ruling which struck down laws against interracial marriage:

“But nearly every discriminatory law is susceptible to a similarly race- or sex-neutral characterization. A prohibition on interracial marriage, for example, allows no person to marry someone outside of her race, while allowing persons of any race to marry within their race….

In a passage that sounds hauntingly familiar to readers of Tennessee’s brief, Virginia argued in Loving that, should this Court intervene, it would find itself in a “bog of conflicting scientific opinion upon the effects of interracial marriage, and the desirability of preventing such alliances, from the physical, biological, genetic, anthropological, cultural, psychological, and sociological point of view.” … “In such a situation,” Virginia continued, “it is the exclusive province of the Legislature of each State to make the determination for its citizens as to the desirability of a policy of permitting or preventing such [interracial] alliances—a province which the judiciary may not constitutionally invade.” Id., at 7–8.

While the ruling is sweeping in its implications for transgender medical care—and could easily be used to justify future restrictions on adult care—the majority sidestepped key constitutional questions. The Court declined to answer whether discrimination against transgender people constitutes sex discrimination, whether transgender people qualify as a protected class warranting heightened scrutiny, or whether the Bostock decision applies beyond the Title VII employment context. A ruling on any of these issues could have turned an already devastating outcome into a catastrophic one, potentially overturning dozens of lower court decisions on bathroom access, forced outing in schools, and participation in sports. Though the majority avoided that outcome, three justices—Justices Samuel Alito, Clarence Thomas, and Amy Coney Barrett—wrote separately to express that they would have gone further, explicitly denying transgender people equal protection under the law.

Several rulings in recent months will remain unaffected by the Court’s decision. Just yesterday, a federal judge certified a class of transgender people in a lawsuit challenging a passport ban and opened the door for gender marker updates. Similarly, rulings blocking the government from stripping funding from organizations that mention transgender issues or gender identity are expected to remain intact, as are decisions involving school bathroom access and participation in sports. As a result, the impact of this ruling is likely to remain confined to the medical context—for now. Still, the decision provides a blueprint for future legislation targeting “gender dysphoria” as a proxy for discriminating against transgender people without explicitly naming transgender status or sex.

“Today’s ruling is a devastating loss for transgender people, our families, and everyone who cares about the Constitution,” said Chase Strangio, Co-Director of the ACLU’s LGBTQ & HIV Project. “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. The Court left undisturbed Supreme Court and lower court precedent that other examples of discrimination against transgender people are unlawful. 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.”

The decision will send shockwaves through the transgender community. By embedding discrimination into Supreme Court precedent, the justices have ensured that transgender Americans will likely spend a generation clawing back rights now imperiled. And yet, the ruling leaves cracks in the foundation—enough space, for now, to regroup and keep fighting. Protective laws in many states remain on the books. Key court victories still stand. It is in those openings, however narrow, that hope persists—and where the fight continues.