The Supreme Court's Skrmetti Ruling Missed Key Sex Discrimination Issues: 5 Insights

The Supreme Court Upholds Tennessee's Gender-Affirming Care Ban, Weakening Equal Protections

On June 18, 2025, the US Supreme Court issued its decision in United States v. Skrmetti, upholding Tennessee’s ban on gender-affirming care for minors. This ruling has sparked significant concern among advocates and legal experts who argue that it undermines equal protection and fails to recognize the discriminatory nature of the law. The decision allows states to target gender-affirming care for transgender youth without triggering constitutional protections typically afforded in such cases.

The Tennessee law, known as SB1, prohibits medical treatments that "enable a minor to identify with, or live as, a purported identity inconsistent with the minor's sex." While the state claims the law is based on age and medical use, in practice, access to treatment is determined entirely by a patient's sex assigned at birth. This means that the same medications can be prescribed to cisgender individuals for other medical conditions but are denied to transgender youth seeking care for gender dysphoria.

This approach raises serious concerns about the law’s compliance with international human rights standards. According to the UN Human Rights Committee, which monitors implementation of the International Covenant on Civil and Political Rights (ICCPR), states are obligated to ensure LGBTQ+ individuals have equal protection under the law, including access to gender-affirming care. By failing to acknowledge how laws like Tennessee’s operate on the basis of gender identity and sex, the Court has opened the door to further restrictions on gender-affirming care and potential reshaping of how discrimination is defined and applied under the law.

A Concerning Narrowing of Equal Protection Doctrine

The Court’s reasoning in Skrmetti is seen as a concerning narrowing of the equal protection doctrine. It accepted Tennessee’s claim that the law does not rely on a sex-based classification, even though the law functions precisely as a result of such a determination. The determining factor is not the treatment itself, but whether it aligns with the sex assigned at birth of the person seeking it.

This decision contradicts the overwhelming medical consensus that gender-affirming care is often life-saving. Denying access to such care has been recognized by the UN Independent Expert on Sexual Orientation and Gender Identity as a form of discrimination that violates the right to the highest attainable standard of health. In upholding Tennessee’s law, which explicitly states its purpose is to "encourage minors to appreciate their sex," the Court has validated discriminatory practices and infringed on the rights of transgender youth.

The Flawed "Medical Purpose" Rationale

The Court characterized SB1 as regulating a class of medical interventions rather than the identity of the patient. However, the "medical purpose" that triggers the ban can only be determined by looking at the patient’s sex and gender identity. In reality, this determination is a regulation of who may access those procedures, and that access is based on sex.

Equal protection law has long recognized that even laws written in neutral terms may still have discriminatory effects, under disparate impact analysis. In this case, the law permits or denies treatment not based on medical risk, efficacy, or clinical guidance, but on whether treatment coincides with ideological views about sex and gender identity. A more rigorous equal protection analysis would have required the Court to examine whether the state’s reasoning truly justifies restricting access to care.

Contradictory Approach: Invoking Bostock While Undermining It

The Supreme Court’s reasoning in Skrmetti departs from the clear logic it applied in Bostock v. Clayton County (2020), where it held that discrimination against transgender individuals on the basis of sexual orientation and gender identity is discrimination under Title VII of the Civil Rights Act. That decision marked a major step forward for LGBTQI+ rights, one that ought to have been central to the Court’s reasoning in Skrmetti.

However, the Court in Skrmetti attempted to differentiate this case from Bostock, asserting that a transgender boy would be denied treatment regardless of his sex assigned at birth, so long as the diagnosis is gender dysphoria. This interpretation relies on a narrow reading of the law that ignores how it works in practice.

A Major Step Backward from Modern Interpretations of Equal Protection

To support its conclusion, the Court relied on Geduldig v. Aiello (1974), a case that upheld the exclusion of pregnancy-related disabilities from insurance coverage. The Geduldig decision reasoned that, because pregnancy is a physical condition and not experienced by all women, the policy did not classify on the basis of sex. That case has long been criticized for its failure to acknowledge that distinctions targeting conditions unique to one sex, like pregnancy, can still constitute sex-based discrimination.

In Skrmetti, the Court adopts a similar rationale. Because the law applies to all minors who seek gender affirming care, regardless of their sex assigned at birth, the Court reasons it is not discriminatory. But this fails to consider that only transgender minors seek such care, and only they are subject to the ban. By reviving the flawed reasoning of Geduldig, the Court enables laws that functionally exclude specific groups to escape heightened constitutional review, so long as the language is carefully crafted.

A Warning Sign for the Future of Sex Equality

The Skrmetti decision reflects a broader shift in equal protection doctrine away from substantive analysis of how laws operate and toward deference to legislative framing. Although SB1 is clearly conditioned on sex and its purpose is ideologically motivated, the Court, in contradiction to human rights law and standards, declines to treat it as a sex-based classification.

This approach risks rendering the Equal Protection Clause ineffective in precisely the kinds of cases where its protections are most needed, where marginalized groups face targeted state action under the guise of neutrality. Without clear and enforceable constitutional protections, such as those the Equal Protection Amendment (ERA) would provide, laws that restrict access to care or other rights based on sex or gender identity can slip through the cracks.

The path forward requires perseverance and vigilance, not only in advocating for stronger legal standards, but in ensuring judges at least uphold existing standards in practice and look to the standards set by international human rights mechanisms. Skrmetti makes clear that relying on outdated legal reasoning leaves too many vulnerable, and that’s a reality we cannot accept. Universal recognition and application of the ERA would go a long way to addressing these challenges.