# United States v. Skrmetti

United States v. Skrmetti (Docket No. 23-477) is a pending United States Supreme Court case on whether bans on transgender medical procedures (including puberty blockers and hormone therapy) for minors under the age of 18 violate the Equal Protection Clause of the Fourteenth Amendment to the United States Constitution.

## Background

As a result of the culture war in the United States since the mid-2010s, transgender rights in the United States have come under attack from conservative groups including the Republican Party and evangelicals. Since 2020, many states with Republican-led legislatures introduced bathroom bills and bills to limit transgender schoolchildren from participating in sports, and while many were defeated or challenged legally, there was public support for these bills in those states, leading the Republicans to further their efforts to limit transgender rights as part of their platform as to draw in support from religious groups.
Every major medical association in the United States has opposed these bans. In June 2023 the Endocrine Society released a statement opposing such bans whose signatories included the American Academy of Pediatrics, American College of Obstetricians and Gynecologists, American Urological Association, American Society for Reproductive Medicine, American College of Physicians, American Association of Clinical Endocrinology, and the American Medical Association (AMA).
On March 22, 2023, the Tennessee House of Representatives passed HB1 amending the Tennessee Code prohibiting certain forms of gender-affirming care for transgender minors with a diagnosis of gender dysphoria. This includes puberty blockers, hormone therapy, and surgeries (though the ban on the latter is not at issue in the case). The bill does not restrain the use of puberty blockers and hormones for other medical purposes such as the treatment of precocious puberty. As of December 2024, 23 other states had similar laws in place which could be affected by the Supreme Court's decision in this case (see List of legislation restricting transgender youth health care in the United States).
Upon passage of the law, the Biden Department of Justice sought an injunction in the US District Court for the Middle District of Tennessee to prevent the law from going into effect on July 1, 2023.
The District Court granted a preliminary injunction, preventing the ban on hormones and puberty blockers from going into effect. The court deemed the state ban as infringing on the "fundamental rights" of parents, while allowing for the ban on gender affirming surgery to remain.

### Plaintiffs

The suit was brought by three transgender teens and their families as well as a Tennessee doctor who treats youth with gender dysphoria. The Biden administration joined the plaintiffs under a law which allows the federal government to join in private suits which allege violations of the Equal Protection Clause. Among the plaintiffs is a 16-year old transgender girl, identified only as "L.W.", and her parents, Brian and Samantha Williams, of Nashville, Tennessee. L.W. is a recipient of gender-affirming hormone therapy, which she says has greatly improved her quality of life, describing the gender dysphoria she experienced before treatment as "real-life body horror", and saying that her treatment allows her to "feel normal." The Tennessee state ban forces the Williams family to travel out-of-state for L.W.'s hormone treatments. Biden administration Solicitor General Elizabeth Prelogar has advocated for the plaintiff's right to be a girl in Tennessee. Samantha Williams criticized the "hypocrisy" of Tennessee lawmakers, who championed "parental rights" with regards to COVID-19, only to infringe on those rights via HB1, saying, "They made this medical decision for our child."

### Sixth Circuit

The District Court's ruling was appealed to the US Court of Appeals for the Sixth Circuit. In a 2–1 decision in July 2023, the Sixth Circuit stayed the lower court's decision to grant a preliminary injunction, applying rational basis review. Chief Judge Jeffrey Sutton wrote that the Tennessee state government was likely to succeed upon their appeal and that the right of parents to control the medical care of their children is not a fundamental right because it is not "deeply rooted in this Nation's history and tradition," a standard set by the Supreme Court in Washington v. Glucksberg (1997). Judge Helene White concurred in part and dissented in part, arguing that the Tennessee law is "likely unconstitutional based on the Plaintiffs’ theory of sex discrimination" and that she would not stay the injunction but rather narrow its scope. However, she agreed that the "District Court abused its discretion in granting a statewide preliminary injunction."
By a 2–1 vote in September 2023, the Sixth Circuit panel reversed the district court's preliminary injunction, with Sutton again writing for the majority and White again dissenting.

## Legal analysis

The government advances two lines of argument by which Tennessee's HB1 violates the Equal Protection Clause of the Fourteenth Amendment: that it discriminates by sex, and that it discriminates by transgender status, which the government contends is a "suspect" (or "quasi-suspect") classification. Either of these forms of discrimination would trigger a heightened scrutiny standard of review which, the government argues, the law would not survive. Gender discrimination has a lower standard of review than racial discrimination: namely, intermediate scrutiny since Craig v. Boren (1976).
A separate due process argument was raised before the lower courts but the Supreme Court declined to consider it.

### Sex discrimination

The government argues that the Tennessee law engages in facial sex discrimination. Because the law allows the use of puberty blockers and hormones for reasons unrelated to transition, the government argues, a patient's sex becomes a determining factor in deciding whether these treatments are permissible; for example, a male adolescent would be permitted to take testosterone as a treatment for delayed puberty, but the same medication would be disallowed for a patient whose birth sex is female (taking it for the purposes of inducing physical changes consistent with a masculine or nonbinary gender identity). The government and families also pointed to the Supreme Court's decision in Bostock v. Clayton County (2020), which upheld that both sexual orientation and gender identity are protected classed covered by anti-discrimination laws under Title VII of the Civil Rights Act of 1964.
Tennessee denies that the law draws classifications based on sex, arguing that it instead draws a distinction according to the purposes for which a treatment is given, distinguishing between "minors seeking drugs for gender transition and minors seeking drugs for other medical purposes".

### Discrimination on transgender status

The government further argues that the bill also warrants heightened scrutiny because it discriminates against transgender individuals who, the government argues, constitute at least a quasi-suspect class. In identifying whether a group constitutes a suspect or quasi-suspect class, the courts look to four criteria:
* The group has historically been discriminated against or have been subject to prejudice, hostility, or stigma.
* They possess an immutable or highly visible trait.
* They lack political power.
* The group's distinguishing characteristic does not inhibit it from contributing meaningfully to society.
The government argues that transgender people as a group meet all four criteria.
Tennessee denies that the bill discriminates on transgender status, arguing again that it distinguishes only different medical uses, and pointing out that, for example, a transgender youth would be permitted to use puberty blockers for purposes unrelated to gender transition (such as to treat precocious puberty). The state further argues that even if the bill were considered to discriminate on transgender status, the court should not "get back in the fraught business of creating suspect classes".
Legal experts consider it very unlikely that the court will accept the government's argument in identifying transgender people as a quasi-suspect class, given that it has been decades since the court identified a new class as suspect or quasi-suspect.

## Supreme Court

On November 6, 2023, the United States petitioned the Supreme Court to hear this case on appeal. The Supreme Court granted certiorari on June 24, 2024. Whereas the government's petition alleged a violation of the Equal Protection Clause, the plaintiffs filed a separate petition for certiorari, which the court did not grant, which additionally presented the theory that the bill violated the Due Process Clause by denying parents the right to make medical decisions for their children.

### Amicus briefs

On November 21, 2024, it was discovered that four of the doctors that were testifying in favor of Tennessee's ban, namely Paul Hruz, Michael Laidlaw, James Cantor, and Stephen B. Levine, had previously been reprimanded by various courts across the country as "conspiratorial, deeply biased, far off and deserving very little weight", three of them had never provided healthcare to transgender youth, and who LGBTQ+ advocates and trans healthcare experts say repeatedly peddle misinformation about transgender health care. Additionally, an analysis of the amicus briefs by SPLC found that 19% of them had been filed by designated anti-LGBTQ+ hate groups and another 10% had been filed by "groups and individuals associated with a network of anti-LGBTQ+ pseudoscience purveyors."
Briefs opposing the ban were submitted by the American Psychological Association, the American Academy of Pediatrics, the American Medical Association, and the World Professional Association of Transgender Health (WPATH), among other medical organizations. The Endocrine Society filed a brief stating the ban "irreparably harms adolescents with gender dysphoria by denying crucial care to those who need it."

### Oral arguments

Oral arguments were heard on December 4, 2024. James Matthew Rice, Tennessee's Solicitor General, argued for the Respondents. Prelogar represented the government, and was joined by ACLU attorney Chase Strangio who argued for the private plaintiffs. Strangio is the first known transgender person to make oral arguments before the Supreme Court of the United States.
From their lines of questioning, court observers opined that Justices Elena Kagan, Sonia Sotomayor and Ketanji Brown Jackson appeared to favor the arguments made by the plaintiffs whereas Justices Clarence Thomas, Samuel Alito, Brett Kavanaugh and John Roberts appeared to favor the arguments made by Tennessee. The putative tacks of Justices Amy Coney Barrett and Neil Gorsuch, were unclear; Gorsuch, who had written the majority opinion in Bostock, did not ask any questions during the session. Barrett was described as seeming sympathetic to Tennessee's position, though was acknowledged as having been less direct in her questioning than Roberts, Thomas, Alito and Kavanaugh. However, court observers also noted that Barrett appeared to be sympathetic to the question of whether the law violates parent's rights to make medical decisions for their children, despite it not being a question in this particular case. This led some to believe that, should the court rule that Tennessee's law does not constitute as sex discrimination in Skrmetti, the law could still be challenged again with a parental rights claim and may be more successful with that argument instead.
Several of the conservative justices during the arguments signaled an openness to creating a carveout from sex discrimination protections, under which such discrimination via government authority would be constitutional in a medical context.

## Prognostication

In November 2024, the Yale Law School hosted a panel to discuss the medical and legal connotations of the case. Legal experts predict that, should the Supreme Court uphold Tennessee's law, access to many other forms of healthcare for both children and adults could also be impacted including gender-affirming care for adults and abortion access as well as other sex-based civil rights and LGBT rights.
Legal experts expected that Donald Trump's second administration would direct his Department of Justice to reverse its stance on the case and withdraw the government's request for the Supreme Court to hear the case. Experts predict that with oral arguments having already taken place, this should have little impact on the case. However, the Supreme Court could decide to hold another hearing for the case. On February 7, 2025, the Department of Justice did in fact reverse its stance and claimed in a letter to the Supreme Court that the Tennessee law does not violate equal protection based on sex or any other characteristic, but maintained that the Court should still proceed with ruling on the case.