Tennessee Law Prohibiting Transgender Care for Minors Upheld by Supreme Court

Case Background & Decision

In March 2023, Tennessee passed a law (SB 1) prohibiting health care providers from administering puberty blockers and hormone treatments for transgender minors.^[1]

SB 1 specifically prohibits health care providers from prescribing, administering, or dispensing any puberty blocker and hormone treatment “for the purpose of enabling a minor to identify with, or live as, a purported identity inconsistent with the minor's sex or treating purported discomfort or distress from a discordance between the minor's sex and asserted identity.”^[2]

In April 2023, the United States Department of Justice (DOJ) joined the plaintiffs^[3] in challenging SB 1 as a constitutional violation of the Equal Protection Clause under the 14th Amendment. After proceeding through the lower courts in 2023 (including a ruling by the Sixth Circuit Court of Appeals upholding SB 1), the United States Supreme Court heard oral argument on the case on December 4, 2024.

On February 7, 2025, the DOJ, under the second Trump administration, notified the Court that their position with respect to SB 1 changed from the prior administration, and contended that SB 1 does not violate the Equal Protection Clause of the 14^th Amendment. Yet, the DOJ did not withdraw its briefs and did not seek to dismiss the case at that time.

The Supreme Court issued their decision regarding this matter on June 18, 2025, upholding SB 1 and ruling that it does not violate the Equal Protection Clause under the 14th Amendment.^[4] Specifically, the Court held that since SB1 does not classify individuals based on sex or transgender status but rather on age and medical use, the law did not trigger heightened scrutiny. As a result, the Court applied the more deferential “rational basis” standard^[5] and upheld SB 1.

Impact to Group Health Plans

The Skrmetti decision arrives at a time when medical care for transgender minors continues to be a sensitive and politically charged issue for various stakeholders, including employers sponsoring group health plans and their impacted employees.

For general reference, the opinion cited “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.”^[6] Justice Roberts, in his majority opinion, also wrote that ‘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.”^[7]

As a result of this ruling, individual states are now permitted to enact their own laws either prohibiting (such as SB 1) or protecting access to this medical care and treatment for transgender minors. As Justice Roberts continued on to declare, “Questions regarding the law’s policy are thus appropriately left to the people, their elected representatives, and the democratic process.”^[8]

The most immediate impact to group health plans involves access to medical care for transgender minors living in states with similar bans to SB 1. As of the date of this publication, 27 states have enacted laws restricting access to such care. Click here for a Kaiser Family Foundation webpage tracking such state-level bans/restrictions.

Of note, certain state ban challenges turn on different issues than the Skrmetti case, which challenged SB 1 on Equal Protection grounds under the 14^th Amendment. Other legal challenges to similar state bans are based instead on parental rights and state constitutional arguments. Multistate employers sponsoring group health plans are advised to closely monitor litigation developments in connection with these state-level bans in light of the Skrmetti ruling to grasp the potential impact to their employees living in these states.

Next Steps for Employer Group Health Plans

Employers sponsoring group health plans should contact their applicable plan service providers (detailed below) regarding any immediate impact of this ruling on their group health plans’ coverage of the relevant treatment and services:

• Fully insured group health plan and non-ERISA^[9] self-funded governmental group health plans are required to adhere to state law and should confer with their health insurance carriers regarding any state-specific laws/regulations around coverage of medical care for transgender minors.

• Self-funded group health plans governed under ERISA are generally exempt from state insurance laws and will typically follow their third-party administrator’s (TPA) and pharmacy benefits manager’s (PBM) medical and pharmacy management policies in this realm, particularly if the TPA/PBM is considered a “covered entity” under Section 1557 of the Affordable Care Act.

  It is important to note, however, that ERISA does not preempt state criminal laws of general applicability (which would seemingly include SB 1). Although SB 1 targets health care providers rather than ERISA group health plans, it is unclear whether an aggressive state prosecutor could attempt to bring action against an ERISA group health plan covering gender-affirming care for “aiding and abetting” a crime under certain state laws.

From a general employee relations angle, employers should be aware, at a high level, that SB 1 and other similar state laws might provide civil and criminal liability penalties and sanctions for health care providers (and even for consenting parents of transgender minors in certain circumstances) for violations of the law.

Ultimately, employer group health plan sponsors are advised to consult with their benefits counsel regarding the legal implications of group health plan coverage of transgender care for minors, including offering a travel assistance benefit and/or telehealth benefit for employees’ transgender minor covered dependents to receive puberty blockers and hormone treatment in a different state.

Broader Landscape

Providing a broader perspective around the landscape here, the Skrmetti decision upholding SB 1 appears to align with the current Presidential administration’s related executive orders (EO), updated guidance, and a recent proposed rule (outlined below):

1. An EO, issued on January 20, 2025, requires agencies to “take all necessary steps, as permitted by law, to end the Federal funding of gender ideology.”
2. An EO, issued on January 28, 2025, with the stated goal to prohibit or limit gender-affirming care for Americans under 19 years old by withholding federal funding and directing federal agencies to take measures to prevent surgeries, hormone therapy, puberty blockers, and other gender identity-related care services. Notably, this EO directs the U.S. Department of Health and Human Services (HHS) Secretary to take “regulatory and sub-regulatory actions” to achieve its goal.
3. HHS recently rescinded its guidance on gender-affirming care from March 2022 as directed by the EO above, stating the 2022 guidance no longer reflects its views.
4. A recent HHS proposed rule that would prohibit non-grandfathered individual and small group market health insurance coverage from providing coverage for what HHS refers to as "sex-trait modifications” (and more commonly known, at least currently, as “gender-affirming care” in health care-related parlance) as an essential health benefit (EHB), beginning with the 2026 benefit plan year. Click here for a Risk Strategies article with more details.

Risk Strategies continues to closely monitor developments in this space and will provide updates when available. In the meantime, contact your Risk Strategies account team with any questions or contact us directly here.

[1] Under SB 1, minor means an individual under eighteen (18) years of age.

[2] Notably, SB 1 allows health care providers to administer puberty blockers or hormones to treat a minor’s congenital defect, precocious puberty, disease, or physical injury.

[3] The plaintiffs were three transgender minors, their parents, and a doctor.

[4] The opinion declined to apply its analysis under the 2020 Bostock v. Clayton County case to this matter. The Bostock case held that discrimination on the basis of sexual orientation constitutes sex discrimination under Title VII of the Civil Rights Act of 1964, which generally applies in the context of employment discrimination.

[5] The Court held there is a rational basis for SB 1’s classifications as the state “concluded that there is an ongoing debate among medical experts regarding the risks and benefits associated with administering puberty blockers and hormones to treat gender dysphoria, gender identity disorder, and gender incongruence.”

[6] United States v. Skrmetti, 605 U.S. ___ (2025)

[7] Id. at 24.

[8] Id.

[9] ERISA stands for the Employee Retirement Income Security Act of 1974.