Gender-Affirming Care: State Laws After SCOTUS Ruling in US v. Skrmetti

The U.S. Supreme Court’s decision in United States v. Skrmetti allows states to restrict gender-affirming care for minors and sets a lower legal standard for evaluating these laws. As a result, access to care now depends heavily on where a patient lives, and constitutional challenges face a steeper path.

The impact extends beyond the courtroom. Patients, parents, and medical professionals are now weighing legal risk alongside medical judgment, while new challenges continue to take shape across the country.

For legal help, connect with a qualified civil rights attorney through the Super Lawyers directory to discuss how this decision may affect your situation.

What Was the Skrmetti Case About?

United States v. Skrmetti originated in Tennessee, where lawmakers passed a law banning puberty blockers, hormone therapy, and sex-transition surgery as treatments for gender dysphoria in minors. Exceptions for medical conditions were included. The law also outlined enforcement mechanisms and a statute of limitations.

In response, three transgender teens, their families, and a Tennessee doctor who treats youth with gender dysphoria filed a lawsuit claiming the law violated the Equal Protection Clause of the Fourteenth Amendment to the U.S. Constitution. During the early stages of the lawsuit, the plaintiffs sought an injunction to stop the law from taking effect while the lawsuit was pending in court.

The federal district court applied heightened scrutiny and blocked the law from taking effect. The U.S. Court of Appeals for the Sixth Circuit applied a less stringent standard of review, the rational basis test, and ruled that the Tennessee law did not discriminate on the basis of sex. Ultimately, the law was allowed to go into effect while the lawsuit was pending.

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The US Supreme Court’s Decision in Skrmetti

The question of what level of judicial scrutiny is required for a law restricting gender-affirming care went to the U.S. Supreme Court. Before the Court issued its ruling, the Trump administration withdrew the Biden administration’s prior support for the plaintiffs.

In a 6-3 decision, the Court sided with the appeals court in upholding Tennessee’s ban on gender-affirming care for minors, ruling that the law doesn’t violate the Equal Protection Clause. The Court reasoned that Tennessee’s law classifies based on age and medical use rather than sex or transgender status. As such, it only triggered rational basis review rather than heightened scrutiny for the protected characteristic of sex.

While the majority found the state had a legitimate interest in regulating medical treatments for minors, the dissenting Justices argued that Tennessee’s ban is effectively sex discrimination. They also warned that this ruling opened the door to broader Equal Protection violations.

Why the Skrmetti Decision Matters Legally

The Skrmetti ruling is significant because it governs lower courts and state laws on gender-affirming care going forward. The ruling also affects how advocates use a prior landmark LGBTQ+ rights case, Bostock v. Clayton County.

In Bostock, the Court held that Title VII of the Civil Rights Act of 1964 prohibits employment discrimination based on sexual orientation and gender identity. The majority opinion reasoned that discrimination against someone for being transgender or gay necessarily involves discrimination “on the basis of sex.”

Challengers to gender-affirming care bans often relied on Bostock to argue that laws targeting transgender individuals should be treated as sex-based discrimination. Courts and agencies also applied Bostock’s reasoning to Section 1557 of the Affordable Care Act, which governs discrimination in healthcare.

In Skrmetti, the Court did not extend Bostock’s reasoning to the Equal Protection context. Instead, it applied a more deferential standard, which makes these constitutional arguments harder to win. However, the Skrmetti ruling isn’t all-encompassing. It does not mandate any nationwide bans on hormone treatment, surgery, or mental healthcare for transgender minors. It also doesn’t apply to adults, only transgender children.

Practical Implications of Skrmetti Across the US

The patchwork system of laws creates uncertainty and confusion for providers, patients, and their families. Access to medical care for transgender youth varies significantly from one state to the next.

For some, this could limit trans rights in their home state, forcing them to travel to neighboring states for medical treatments. This can create increased legal and financial burdens. Research from UCLA School of Law’s Williams Institute estimates that a significant number of transgender youth live in states where access is restricted or under legal challenge.

For medical providers, there are increased risks associated with operating a medical practice that provides care to trans youth. These professionals could face licensing penalties, civil liability, and increased regulatory scrutiny. Complying with rapidly changing state laws can become challenging.

Employers and insurers must also track state laws, as they can directly affect coverage. Medical procedures that were once covered may no longer be legal, and thus, insurance coverage terms must be updated. This can create potential complications for employers, who must comply with state and federal anti-discrimination laws when employing transgender people.

Gender Affirming Care Laws by State

What Legal Challenges Come Next

Even after Skrmetti, legal challenges are continuing. Some challenges will rely on substantive due process, arguing for parental rights and the ability to make medical decisions without undue state interference. Others will test First Amendment protections, particularly in cases involving provider speech and professional discretion.

Statutory claims in federal courts are also gaining attention. Section 1557 of the Affordable Care Act continues to serve as a basis for discrimination claims in healthcare settings. Title VII may apply to employment-related disputes involving coverage or workplace protections.

State-level litigation is expected to expand. Some state constitutions recognize broader protections for privacy, autonomy, and equal rights, which may support challenges even where federal claims fall short.

Over time, conflicting rulings across jurisdictions could return these issues to the Supreme Court. The American Civil Liberties Union (ACLU) continues to be involved in litigation challenging these laws, which means the legal landscape may continue to shift.

A New Legal Era for Gender-Affirming Care

After United States v. Skrmetti, gender-affirming care law is no longer governed by a single national standard but by a patchwork of state-level rules. This creates real legal consequences for patients seeking care, medical professionals providing treatment, and families trying to make informed decisions. As litigation continues and states refine their laws, the need for individualized legal advice becomes even more important.

Use the Super Lawyers directory to connect with a civil rights attorney who can help you navigate this evolving area of law.