U.S. v. Skrmetti, No. 23-477 [Arg: 12.4.2024]

The Sidebar: Supreme Court of the United States

This episode discusses the Supreme Court oral argument in the case United States v. Skrmetti. The case centers on the constitutionality of a Tennessee law (SB1) restricting access to gender-affirming care for minors. The petitioner argues SB1 constitutes unlawful sex discrimination, requiring heightened judicial scrutiny under the Equal Protection Clause. The respondents contend the law is justified by legitimate health concerns and does not create an unconstitutional sex-based classification. The justices' questions explore the complexities of balancing competing interests, the appropriate standard of review, and the evolving medical understanding of gender dysphoria.

Questions:
1. How does L.W. v. Skrmetti redefine sex-based classifications?
The case discuss how L.W. v. Skrmetti redefines sex-based classifications by arguing that Tennessee’s Senate Bill 1 (SB1), which bans certain medical treatments for minors with gender dysphoria, is a facial sex classification because:

• SB1 prohibits medical care based on inconsistency with one’s sex assigned at birth, creating different rules for those assigned male versus those assigned female. For instance, an adolescent assigned female at birth cannot receive medication to live as male, but someone assigned male at birth can receive medication to live as male. This creates a parallel set of restrictions for individuals based solely on their sex.
• The purpose of the law is to encourage minors to live consistently with their sex assigned at birth, further reinforcing the sex-based classification.1356 The legislature was explicit in stating that the law aims to ensure that adolescents appreciate their sex and live in accordance with traditional gender expectations.

However, Tennessee argues that the law is not discriminatory because it draws lines based on: Age, prohibiting the medical treatments in question only for minors.

• Medical purpose, arguing that using hormones for gender transition is distinct from using them for other purposes. For example, they argue that using testosterone to treat a deficiency in a biological male is different from using it to treat a biological female who seeks to transition.

2. What medical uncertainties complicate the L.W. v. Skrmetti ruling?

• The sources center on a debate regarding the medical uncertainties and risks surrounding the use of puberty blockers and hormones for the treatment of gender dysphoria in minors, specifically within the context of the L.W. v. Skrmetti case.
• The Solicitor General argues that there is a consensus that these treatments can be medically necessary for some adolescents1. However, this is disputed by Justice Alito, who points to the Swedish National Board of Health and Welfare and the Cass report in the United Kingdom as evidence suggesting that the risks of these treatments outweigh the benefits for minors.
• The Solicitor General acknowledges the debate and evolving standards surrounding gender-affirming care but maintains that puberty blockers and hormones can have critical benefits for individuals with severe gender dysphoria, including a reduction in suicidal ideation and attempts.
• The Solicitor General clarifies that while some individuals may regret undergoing gender-affirming care, the rates of regret are very low, especially for adolescents who have experienced persistent gender dysphoria that worsened with puberty.
• Mr. Strangio, counsel for the petitioners, similarly emphasizes that medications can reduce the risk of depression, anxiety, and suicidality in minors experiencing gender dysphoria5. He also highlights that the regret rate for those receiving treatment after the onset of puberty is as low as 1%, significantly lower than regret rates for other treatments permitted by SB1.
• Mr. Rice, counsel for the respondents, argues that the use of puberty blockers and hormones for treating gender dysphoria is "risky" and "unproven". He supports Tennessee's decision to restrict these interventions, citing European countries like Sweden, Finland, and the UK, which have also imposed limitations8. He stresses that these interventions can have "irreversible and life-altering consequences" and that European health authorities have not found any established benefits.
• Justice Alito specifically questions the assertion that gender-affirming care reduces the risk of suicide, asking Mr. Strangio whether this claim is "clearly established" or if there is "reason for disagreement". Mr. Strangio responds by affirming that the medications reduce suicidality but acknowledges that there is ongoing research and debate in this area.