CONSTITUTIONAL LAW – FOURTEENTH AMENDMENT – EQUAL PROTECTION – TRANSGENDER MEDICAL CARE

United States v. Skrmetti, 145 S. Ct. 1816 (June 18, 2025)
Roberts, C. J., delivered the opinion of the Court, in which Thomas, Gorsuch, Kavanaugh, and Barrett, JJ., joined, and in which Alito, J., joined as to Parts I and II-B. Thomas, J., filed a concurring opinion. Barrett, J., filed a concurring opinion, in which Thomas, J., joined. Alito, J., filed an opinion concurring in part and concurring in the judgment. Sotomayor, J., filed a dissenting opinion, in which Jackson, J., joined in full, and in which Kagan, J., joined as to Parts I-IV. Kagan, J., filed a dissenting opinion.
Chief Justice Roberts delivered the opinion of the Court.
In this case, we consider whether a Tennessee law banning certain medical care for transgender minors violates the Equal Protection Clause of the Fourteenth Amendment.
An estimated 1.6 million Americans over the age of 13 identify as transgender, meaning that their gender identity does not align with their biological sex. See 1 App. 257-259; 2 id., at 827. Some transgender individuals suffer from gender dysphoria, a medical condition characterized by persistent, clinically significant distress resulting from an incongruence between gender identity and biological sex. Left untreated, gender dysphoria may result in severe physical and psychological harms.
SB1 responds to these concerns by banning the use of certain medical procedures for treating transgender minors. In [***13] particular, the law prohibits a healthcare provider from “[s]urgically removing, modifying, altering, or entering into tissues, cavities, or organs of a human being,” or “[p]rescribing, administering, or dispensing any puberty blocker or hormone,” §68-33-102(5), for the purpose of (1) “[e]nabling a minor to identify with, or live as, a purported identity inconsistent with those objectives.” Virginia, 518 U. S., at 533, 116 S. Ct. 2264, 135 L. Ed. 2d 735
(internal quotation marks omitted).
We are asked to decide whether SB1 is subject to heightened scrutiny under the Equal Protection Clause. We hold it is not. SB1 does not classify on any bases that warrant heightened review.
On its face, SB1 incorporates two classifications. First, SB1 classifies on the basis of age. Healthcare providers may administer certain medical treatments [**151] to individuals ages 18 and older but not to minors. Second, SB1 classifies on the basis of medical use. Healthcare providers may administer puberty blockers or hormones to minors to treat certain conditions but not to treat gender dysphoria, gender identity disorder, or gender incongruence. Classifications that turn on age or medical use are subject to only rational basis review. See Massachusetts Bd. of Retirement v. Murgia, 427 U. S. 307, 312-314, 96 S. Ct. 2562, 49 L. Ed. 2d 520 (1976)
( [***19] per curiam) (rational basis review applies to age-based classification); Vacco v. Quill, 521 U. S. 793, 799-808, 117 S. Ct. 2293, 138 L. Ed. 2d 834 (1997) (state laws outlawing assisted suicide “neither infringe fundamental rights nor involve suspect classifications”).
The plaintiffs argue that SB1 warrants heightened scrutiny because it relies on sex-based classifications. We disagree.
We have explained that a State does not trigger heightened constitutional scrutiny by regulating a medical procedure that only one sex can undergo unless the regulation is a mere pretext for invidious sex discrimination. In Geduldig v. Aiello, 417 U. S. 484, 94 S. Ct. 2485, 41 L. Ed. 2d 256 (1974), for example, we held that a California insurance program that excluded from coverage certain disabilities resulting from pregnancy did not discriminate on the basis of sex.
SB1 does not exclude any individual from medical treatments on the basis of transgender status but rather removes one set of diagnoses—gender dysphoria, gender identity disorder, and gender incongruence—from the range of treatable conditions. SB1 divides minors into two groups: those who might seek puberty blockers or hormones to treat the excluded diagnoses, and those who might seek puberty blockers or hormones to treat other conditions. See Tenn. Code Ann. §68-33-103. Because only transgender individuals seek puberty blockers and hormones for the excluded diagnoses, the first group includes only transgender individuals; the second group, in contrast, encompasses both transgender and nontransgender individuals. Thus, although only transgender individuals seek treatment for gender dysphoria, gender identity disorder, and gender incongruence—just as only biological women can become pregnant—there is a “lack of identity” between transgender status and the excluded medical diagnoses. The plaintiffs, moreover, have not argued that SB1’s prohibitions are mere pretexts designed to effect an invidious discrimination against transgender individuals. Under these circumstances, we decline to find that SB1’s prohibitions on the use of puberty blockers and hormones exclude any individuals on the basis of transgender status.
The rational basis inquiry “employs a relatively relaxed standard reflecting the Court’s awareness that the drawing of lines that create distinctions is peculiarly a legislative task and an unavoidable one.” Massachusetts Bd. of Retirement, 427 U. S., at 314, 96 S. Ct. 2562, 49 L. Ed. 2d 520. Under this standard, we will uphold a statutory classification so long as there is “any reasonably conceivable state of facts that could provide a rational basis for the classification.” FCC v. Beach Communications, Inc., 508 U. S. 307, 313, 113 S. Ct. 2096, 124 L. Ed. 2d 211 (1993). Where there exist “plausible reasons” for the relevant government action, “our inquiry is at an end.” Id., at 313-314, 113 S. Ct. 2096, 124 L. Ed. 2d 211 (internal quotation marks omitted).
We also decline the plaintiffs’ invitation to second-guess the lines that SB1 draws. It may be true, as the plaintiffs contend, that puberty blockers and hormones carry comparable risks for minors no matter the purposes for which they are administered. But it may also be true, as Tennessee determined, that those drugs carry greater risks when administered to treat gender dysphoria, gender identity disorder, and gender incongruence. We afford States “wide discretion to pass legislation in areas where there is medical and scientific uncertainty.” Gonzales v. Carhart, 550 U. S. 124, 163, 127 S. Ct. 1610, 167 L. Ed. 2d 480 (2007). “[T]he fact the line might have been drawn differently at some points is a matter for legislative, rather than judicial, consideration.” Railroad Retirement Bd. v. Fritz, 449 U. S. 166, 179, 101 S. Ct. 453, 66 L. Ed. 2d 368 (1980); see Dandridge v. Williams, 397 U. S. 471, 485, 90 S. Ct. 1153, 25 L. Ed. 2d 491 (1970) (“In the area of economics and social welfare, a State does not violate the Equal Protection Clause merely because the classifications made by its laws are imperfect.”); Lindsley v. Natural Carbonic Gas Co., 220 U. S. 61, 78, 31 S. Ct. 337, 55 L. Ed. 369 (1911) (“A classification having some reasonable basis does not offend against [the Equal Protection Clause] merely because it is not made with mathematical nicety or because in practice it results in some inequality.”).
This case carries with it the weight of fierce scientific and policy debates about the safety, efficacy, and propriety of medical treatments in an evolving field. The voices in these debates raise sincere concerns; the implications for all are profound. The Equal Protection Clause does not resolve these disagreements. Nor does it afford us license to decide them as we see best. Our role is not “to judge the wisdom, fairness, or logic” of the law before us, Beach Communications, 508 U. S., at 313, 113 S. Ct. 2096, 124 L. Ed. 2d 211, but only to ensure that it does not violate the equal protection guarantee of the Fourteenth Amendment. Having concluded it does not, we leave questions regarding its policy to the people, their elected representatives, and the democratic process.
The judgment of the United States Court of Appeals for the Sixth Circuit is affirmed.