United States v. Skrmetti: U.S. Supreme Court Rules on Tennessee Ban on Gender-Affirming Care for Minors

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On June 18, 2025, in United States v. Skrmetti, the U.S. Supreme Court upheld Tennessee’s Senate Bill 1 (the “Bill”), which bans gender-affirming medical treatments, such as puberty blockers, hormone therapy, and surgeries, for minors. In a 6-3 decision, the Court concluded that the Bill survives the rational-basis review under the Equal Protection Clause of the Fourteenth Amendment and clarified that it does not constitute impermissible sex discrimination, as further detailed below. This article primarily focuses on the significance of this ruling to employers who offer health and welfare plans; however, its ripple effects extend to medical treatment in other aspects as well, which is beyond the scope of this article.

Background

The Bill was enacted in March 2023 in Tennessee and broadly prohibited any licensed healthcare provider from administering or prescribing puberty blockers, hormone therapies, and related procedures to minors for gender-affirming purposes. Notably, these treatments were preserved for other medical purposes besides treating gender dysphoria, gender identity disorder, or gender incongruence. The plaintiffs, including families of the impacted transgender youth, challenged the Bill in federal court claiming it violated their rights under the Equal Protection Clause and the First Amendment. The district court upheld the Bill under a rational-basis review, which was further affirmed by the Sixth Circuit Court of Appeals. The U.S. Supreme Court subsequently granted certiorari.

Key Takeaways

The following are some of the key takeaways from the Supreme Court’s opinion in Skrmetti:

• On the face of the language of the Bill, there is no discrimination on the basis of sex or transgender status, but rather the Bill classifies individuals only on the basis of age and “medical use.” “While [the Bill’s] prohibitions reference sex, the Court has never suggested that mere reference to sex is sufficient to trigger heightened scrutiny.”
• The Court determined that the review of the Bill only warrants a rational basis standard, given the fact that: (i) the ban applies equally to all minors seeking gender-affirming care without reference to sex; and (ii) age and “medical use” are not suspect classes subject to the heightened scrutiny.
• Rational-basis review only asks whether the law is rationally, or plausibly, related to a legitimate government interest. Tennessee stated its interests as preventing minors from making irreversible medical decisions and avoiding safety risks. The Court viewed these reasons as “rational” based on precedent. Notably, the Court did not resolve the question of whether transgender status is a protected class.

Employer Impact

Although Skrmetti mainly focuses on the healthcare providers’ conduct in relation to gender-affirming care for youth in Tennessee, the ruling nevertheless prompts important considerations nationwide. The Court’s ruling is significant insofar as similar bans in other states are to be challenged on the same grounds as Skrmetti—such challenges are likely to fail. As explained above, the Bill applies primarily to healthcare providers, and there is no law prohibiting group health plans from covering gender-affirming care for minors so long as it is legal where provided. Employers contemplating exclusions of gender-affirming care for minors should work with their consultants or legal counsel regarding the risk of potential discrimination claims under federal law, such as Title VII of the Civil Rights Act of 1964.

Self-funded plans are, of course, exempt from state insurance mandates (even if one existed) by way of federal law preemption; however, some employers adopt state-mandated benefits voluntarily. Thus, all employers should review plan documents for any exclusions of transgender coverage. In particular, employers with fully-insured plans should engage carriers to understand any post-Skrmetti changes to coverage for gender-affirming care in Tennessee and elsewhere, particularly in the 25 jurisdictions with existing bans. Employers should work with their third-party administrators to determine what services are covered to assess the impact of these state laws on plan participants seeking gender-affirming care for minors. Upon review of current coverage, employers should consider furnishing member communications regarding coverage and claim administration assistance with respect to gender-affirming coverage.

Conclusion

All in all, the Court’s decision in Skrmetti will likely make gender-affirming care for minors increasingly hard to access. The practical impact on an employer is likely to depend on the state in which the employer is located and whether such a state has a ban on such medical treatment. Employers should consider the effect on their benefit plan strategies on a case-by-case basis and contact their benefits consultant or legal counsel in the event of any questions.