United States v. Skrmetti

Majority — Roberts

Joined by: Thomas, Gorsuch, Kavanaugh, Barrett, Alito

Chief Justice Roberts reasoned that SB1 contains only two facial classifications—age (minors vs. adults) and medical use (treatment for gender dysphoria vs. other conditions)—neither of which turns on sex, so only rational basis review applies. The majority explained that the law does not prohibit treatments for one sex while allowing them for the other; rather, it bars a particular medical use (treating gender dysphoria) for all minors regardless of sex, and permits puberty blockers and hormones for any minor for other diagnoses. Relying on Geduldig v. Aiello, the Court concluded SB1 similarly does not classify by transgender status because it removes a diagnosis category, not a group of people, from covered treatment, and only transgender individuals fall within the excluded diagnoses while the permitted-treatment group includes both transgender and non-transgender minors. The majority also declined to extend Bostock's employment-discrimination reasoning to equal protection analysis, finding that changing a hypothetical patient's sex would not change the outcome under SB1 once the diagnosis is properly accounted for. In response to the dissent's argument that sex remains a but-for cause because diagnosis substitution occurs alongside sex change, the majority answered that unlike in Bostock, there is no automatic, one-to-one link between a minor's sex and a diagnosis, so sex is not a but-for cause of SB1's operation. Under rational basis review, the Court found Tennessee's stated concerns—irreversible sterility, disease risk, psychological harm, and scientific uncertainty—sufficient to sustain the law, emphasizing that legislatures deserve wide latitude in areas of medical and scientific uncertainty.

Dissent reasoning

Justice Sotomayor, joined fully by Justice Jackson and largely by Justice Kagan, argued that SB1 plainly classifies on the basis of sex because access to puberty blockers and hormones depends on whether the minor's sex is consistent with the desired treatment outcome—a female-born minor can get testosterone-suppressing treatment for one condition but not another, while a male-born minor faces the opposite rule. She argued this is analogous to a law banning attendance at religious services 'inconsistent with' one's religion, which everyone would recognize as a religious classification, and that Bostock's reasoning confirms discrimination based on inconsistency between sex and gender identity is sex discrimination. She further contended that SB1 also classifies by transgender status because desiring to identify with an identity inconsistent with one's sex is definitionally what makes someone transgender, and argued that Geduldig should not be extended beyond its narrow pregnancy context. Sotomayor also argued transgender people meet the criteria for a quasi-suspect class given historical discrimination, an immutable-enough defining trait, and political vulnerability. In Part V, joined only by Jackson, she argued the majority should have remanded for application of intermediate scrutiny rather than avoiding the analysis altogether. Justice Kagan, dissenting separately, agreed with Parts I through IV of Sotomayor's dissent that heightened scrutiny should apply, but declined to join Part V, stating she would not decide whether SB1 survives that scrutiny and would instead leave that fact-intensive question to the lower courts on remand, since neither party had asked the Court to resolve it directly.