On Wednesday, June 18, 2025, the Supreme Court of the United States issued a landmark 6-3 decision in United States v. Skrmetti, directly addressing the constitutionality of state laws banning gender-affirming care for minors. This decision effectively gives states a green light to enact and enforce laws banning or severely restricting gender-affirming care for minors, and significantly alters the legal landscape for such care nationwide.
Skrmetti’s Landmark Ruling
In Skrmetti, the Supreme Court reversed lower court rulings that had blocked Tennessee’s ban on gender-affirming care for transgender minors. The Court held that Tennessee’s law, which prohibits medical treatments like puberty blockers or hormone therapy for transgender adolescents under the age of 18, does not violate the Equal Protection Clause of the Fourteenth Amendment and is not subject to heightened scrutiny.
The majority reasoned that the Tennessee law does not draw a sex-based line that warrants a higher level of judicial review (like intermediate or strict scrutiny). Instead, the Court applied the “rational basis” standard of review, finding the state had a legitimate government interest in regulating medical treatments for minors and the ban was rationally related to that interest. The Court gave deference to the state’s arguments regarding the “experimental” nature of such care and concerns about potential irreversible effects on minors.
Here are five key takeaways from Skrmetti:
- State Bans Upheld. The ruling paves the way for states to enact and enforce laws banning or severely restricting gender-affirming care for minors. This decision is expected to embolden other states to pass legislation similar to Tennessee’s or reinforce existing bans previously challenged on Equal Protection grounds. Approximately half of U.S. states have now enacted such bans, and most of these are now likely to withstand Equal Protection challenges.
- Rational Basis Review. The Court’s application of rational basis review, a deferential standard, significantly lowers the bar for states to defend these bans. To succeed in an Equal Protection challenge, the plaintiff must establish that the law in question is not rationally related to a legitimate government interest. Most laws banning gender-affirming care for minors are likely to survive this review.
- Limits the Reach of Bostock. The Supreme Court declined to address the question of whether the reasoning in Bostock v. Clayton County extends beyond the employment context. This 2020 Bostock decision held discrimination “because of sex” includes discrimination based on gender identity. Nevertheless, applying the logic of Bostock, the Court held in Skrmetti that neither sex nor transgender status is the but-for cause of a minor’s inability to obtain gender identity-based medical care under the Tennessee law at issue.
- Limited Federal Intervention on Equal Protection Grounds. The Supreme Court’s decision directly undermines the federal government’s ability to challenge such state laws on Equal Protection grounds. It is worth noting that Skrmetti addressed only Equal Protection Clause challenges; it does not foreclose challenges on other constitutional or statutory grounds. The application of the rational basis review standard, however, creates a strong undercurrent that could influence lower courts’ willingness to interpret other federal protections in this area broadly.
- Reinforces State Authority. The ruling strengthens the ability of states to regulate medical practices concerning minors within their borders, particularly when those regulations are framed as protecting children.
Pre-Skrmetti Landscape: Executive Orders and Federal Agency Responses
The Skrmetti decision arrives amidst an already complex federal landscape, shaped by recent executive actions and agency responses that sought to restrict gender-affirming care. These prior developments provide critical context for understanding the current environment.
Presidential Executive Orders
One week into his presidency, Donald Trump issued two relevant executive orders:
- EO 14187 (“Protecting Children from Chemical and Surgical Mutilation”): This order directs federally funded institutions to stop providing gender-affirming care to people under the age of 19 and instructs federally run insurance programs (Medicare, Medicaid, TRICARE) to exclude coverage for such care. It also directs the Department of Justice (DOJ) to prioritize investigations and litigation to enforce these directives.
- EO 14168: This related order mandates that federal agencies recognize only two sexes—male and female—and promises to “enforce all sex-protective laws to promote this reality.”
These Executive Orders were met with immediate concern, as they threatened the potential loss of federal funding for healthcare providers and jeopardized the ability to provide care in their respective communities. Some health systems responded by suspending or pausing gender-affirming care for youth. Others continued treating those already receiving care but declined to take new patients.
Challenges to EO 14187 filed in federal court in Maryland and the state of Washington resulted in preliminary injunctions staying enforcement of the executive order. This gave temporary relief to healthcare systems providing gender-affirming care to minors pre-Skrmetti. The injunction in PFLAG, Inc. v. Trump, a case brought by civil rights interest groups, applied nationwide. The ruling in State of Washington v. Trump, applied only to the four plaintiff states. Both lower court rulings were immediately appealed by the Trump administration to the Fourth Circuit and the Ninth Circuit, respectively, where the cases remain pending.
Skrmetti does not directly address the legality of this EO, but it could influence the overall judicial climate and weaken the Equal Protection arguments in these cases pending on appeal. These EO challenges rely on a mix of arguments, including those based on the separation of powers and the Administrative Procedure Act. The Courts of Appeals will determine the viability of arguments distinct from those brought under the Equal Protection Clause.
Department of Health and Human Services Actions
In response to the Executive Orders, the Department of Health and Human Services (HHS) and its agencies took several steps. On February 20, 2025, the HHS Office for Civil Rights (OCR) announced the rescission of its 2022 “Notice and Guidance on Gender Affirming Care, Civil Rights, and Patient Privacy.” This previous guidance had affirmed that Section 1557 of the Affordable Care Act (ACA) protected transgender individuals seeking gender-affirming care. Its rescission signaled a significant shift in HHS’s interpretation of civil rights protections.
The Centers for Medicare & Medicaid Services (CMS) cautioned about the use of federal funds for gender-affirming care for minors and sent letters requesting detailed information about hospitals’ practices related to the treatment of gender dysphoria in minors. Additionally, the Office of Personnel Management (OPM) also instructed insurers for federal employees to exclude coverage for gender-affirming care for individuals under 19 for the 2026 plan year.
Post-Skrmetti Relevance: Attorney General’s Enforcement Memorandum
Adding another layer of complexity and concern for providers, on April 22, 2025, U.S. Attorney General Pam Bondi issued a memorandum titled “Preventing the Mutilation of American Children” to various components of DOJ. This memorandum outlines DOJ’s enforcement stance regarding gender-affirming care for minors.
By validating state bans and applying a deferential standard of review, the Skrmetti decision significantly strengthens the DOJ’s hand in pursuing its stated objectives, even if direct enforcement of EO 14187 remains temporarily enjoined.
Key aspects of Attorney General Bondi’s memorandum include:
- Directive to Investigate and Prosecute. The memo directs federal prosecutors to prioritize investigations and, where appropriate, pursue civil and criminal charges against providers of gender-affirming care to minors.
- Novel Interpretation of Existing Laws. The memo suggests applying the federal Female Genital Mutilation (FGM) Statute to certain gender-affirming surgical procedures for minors. This is a novel and controversial interpretation of a law that has traditionally been understood to address a distinct form of abuse. The memo also calls for investigations under the Food, Drug, and Cosmetic Act (FDCA) for alleged “misleading” statements or “off-label” promotion of medications, and the False Claims Act (FCA) for claims submitted to federal healthcare programs for gender-affirming services.
- Rejection of Medical Consensus. The memo explicitly directs the DOJ to cease reliance on established medical guidelines, such as those from World Professional Association for Transgender Health (WPATH), which support gender-affirming care as medically necessary. This position is implicitly bolstered by the Supreme Court's willingness in Skrmetti to defer to state legislative judgments over medical consensus.
- Call for New Legislation. AG Bondi also stated she has directed the drafting of new legislation to create a private right of action, allowing individuals and their families to sue medical professionals who provide gender-affirming care to minors.
This memorandum signals a clear intent from DOJ to pursue enforcement actions and curtail gender-affirming care for minors using existing laws and new legislative tools.
Implications for Healthcare Systems
The Supreme Court’s decision in United States v. Skrmetti empowers states to restrict gender-affirming care for minors. This ruling, combined with the administration’s executive orders and DOJ’s enforcement posture, creates an exceptionally fluid and fraught environment for healthcare providers who treat transgender youth.
While the preliminary injunctions against EO 14187 offer some temporary federal funding protection, the administration is clearly committed to restricting access to gender-affirming care for minors through multiple avenues, now with significant judicial backing.
In light of Skrmetti, healthcare systems and professionals who provide care for transgender minors should critically evaluate obligations under applicable state laws and closely monitor ongoing litigation that may impact the broader legal landscape. Providers should engage experienced counsel to help navigate an evolving and often contentious legal and political landscape.
Woods Rogers continues to monitor these developments closely and will provide updates as they become available.
