The Story: In a 6–3 ruling, the Supreme Court upheld a Tennessee law restricting certain medical treatments for transgender minors, marking another significant victory for parental rights in protecting children from potentially harmful medical interventions.
The Background: Tennessee’s Senate Bill 1 (SB1) prohibits health-care providers from prescribing puberty blockers or cross-sex hormones to minors for the purpose of enabling them to “identify with, or live as, a purported identity inconsistent with the minor’s sex” or treating “discomfort or distress from a discordance between the minor’s sex and asserted identity.” The law allows these same medications to treat legitimate medical conditions, such as congenital defects, physical injuries, or precocious puberty (a condition where puberty starts earlier than the typical age range).
The legislation came in response to concerns about the experimental nature of these treatments and their potentially irreversible effects, including sterility, increased disease risk, and adverse psychological consequences. Tennessee’s legislature found that minors “lack the maturity to fully understand and appreciate the life-altering consequences” of such procedures and that many individuals have expressed regret for undergoing these treatments as children.
Three transgender minors, their parents, and a doctor challenged SB1, arguing it violated the Equal Protection Clause by discriminating based on sex and transgender status. The Biden administration intervened, supporting the challenge and demanding heightened constitutional scrutiny of the law.
In the Court’s decision in this case, known as United States v. Skrmetti, Chief Justice John Roberts (writing for the majority and joined by Justices Alito, Barrett, Gorsuch, Kavanaugh, and Thomas) ruled that SB1 doesn’t classify based on sex or transgender status and therefore requires only rational basis review—the most deferential standard of constitutional analysis.
“SB1 incorporates two classifications,” Roberts explained, “one based on age (allowing treatments for adults but not minors) and another based on medical use (permitting certain medications for legitimate medical conditions but not for treating gender dysphoria). Classifications based on age or medical use are subject to only rational basis review.” The Court rejected arguments that these constituted sex-based classifications, noting that the law applies equally regardless of a minor’s biological sex.
The Court also distinguished this case from precedents involving employment discrimination, clarifying that changing a minor’s sex wouldn’t alter the application of SB1. The law prohibits specific treatments for specific purposes, not treatments based on the patient’s sex.
Under rational basis review (which tests whether the government’s actions are “rationally related” to a legitimate government interest), the Court found Tennessee’s law easily satisfied constitutional requirements. The state had legitimate concerns about protecting minors’ health and welfare.
The three-justice dissent, led by Justice Sotomayor, would have applied heightened scrutiny and potentially struck down Tennessee’s law. This approach would have prioritized adult political preferences over children’s welfare and undermined state authority to regulate dangerous medical practices.
Why It Matters: This case represented a critical intersection of religious liberty, parental rights, medical ethics, and the government’s role in health-care decisions. But at its heart, the case was about protecting the welfare of vulnerable children.
The ruling affirms that parents, not government bureaucrats or activist medical associations, should have primary authority over their children’s medical decisions. Tennessee’s law—which is similar to laws in 24 other states—respects parental concerns about experimental treatments while protecting children from potentially harmful interventions they cannot fully comprehend.
The Court also acknowledged that states have wide discretion to protect minors from experimental and risky medical procedures. Justice Thomas’s concurrence detailed the serious risks associated with puberty blockers and cross-sex hormones, including potential sterility, cardiovascular complications, and psychological harm.
Additionally, the majority opinion noted that health authorities in Sweden, Finland, and the United Kingdom have all restricted these treatments after determining insufficient evidence of benefits. The Court is correct to defer to legislative judgment in areas of “medical and scientific uncertainty.” This is especially necessary when medical organizations are compromised by ideological concerns rather than focusing solely on patient welfare. For example, Justice Thomas’s concurrence exposed how the World Professional Association for Transgender Health allowed political ideology to influence their medical recommendations, even removing age limits for surgeries after pressure from the Biden administration.
The decision also provides important clarity on constitutional analysis. The Court refused to expand heightened scrutiny to new categories, recognizing that such classifications have been “exceedingly rare” and require extraordinary justification. Justice Barrett’s concurrence explained why transgender status doesn’t qualify as a suspect class, noting the category’s diverse and amorphous nature and the absence of immutable characteristics.
This ruling continues a positive trend of the Court respecting democratic processes and parental rights rather than imposing ideologically driven interpretations of constitutional rights. Like the Court’s victories in religious liberty cases, this decision affirms that constitutional principles protect families and communities from overreaching government mandates.
As Justice Thomas concluded, this case “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.” In protecting Tennessee’s authority to safeguard its children, the Court has struck a blow for parental rights, constitutional federalism, and the fundamental principle that protecting children takes precedence over the ideology of expressive individualism.
Christians should respond to this victory with both gratitude and humility: gratitude for a Court that recognizes parental rights and children’s welfare, and humility as we seek to minister with grace and truth to families navigating these difficult questions. As always, we remember that our ultimate hope isn’t in legal victories alone but in the transforming power of the gospel to bring healing and wholeness to broken lives and fractured families.
The Gospel Coalition