United States v. Skrmetti (605 U.S. 495, 2025)

PRELIMINARY PRINT Volume 605 U. S. Part 2 Pages 495–608 OFFICIAL REPORTS OF THE SUPREME COURT June 18, 2025 Page Proof Pending Publication REBECCA A. WOMELDORF reporter of decisions NOTICE: This preliminary print is subject to formal revision before the bound volume is published. Users are requested to notify the Reporter of Decisions, Supreme Court of the United States, Washington, D. C. 20543, pio@supremecourt.gov, of any typographical or other formal errors. OCTOBER TERM, 2024 495 Syllabus UNITED STATES v. SKRMETTI, ATTORNEY GENERAL AND REPORTER FOR TENNESSEE, et al. certiorari to the united states court of appeals for the sixth circuit No. 23–477. Argued December 4, 2024—Decided June 18, 2025 In 2023, Tennessee joined the growing number of States restricting sex transition treatments for minors by enacting the Prohibition on Medical Procedures Performed on Minors Related to Sexual Identity, Senate Bill 1 (SB1). SB1 prohibits healthcare providers from prescribing, adminis- tering, or dispensing puberty blockers or hormones to any minor for the purpose of (1) enabling the minor to identify with, or live as, a purported identity inconsistent with the minor's biological sex, or (2) treating pur- ported discomfort or distress from a discordance between the minor's biological sex and asserted identity. At the same time, SB1 permits a healthcare provider to administer puberty blockers or hormones to treat a minor's congenital defect, precocious puberty, disease, or physical Page Proof Pending Publication injury. Three transgender minors, their parents, and a doctor challenged SB1 under the Equal Protection Clause of the Fourteenth Amendment. The District Court partially enjoined SB1, fnding that transgender individu- als constitute a quasi-suspect class, that SB1 discriminates on the basis of sex and transgender status, and that SB1 was unlikely to survive intermediate scrutiny. The Sixth Circuit reversed, holding that the law did not trigger heightened scrutiny and satisfed rational basis review. This Court granted certiorari to decide whether SB1 violates the Equal Protection Clause. Held: Tennessee's law prohibiting certain medical treatments for transgen- der minors is not subject to heightened scrutiny under the Equal Pro- tection Clause of the Fourteenth Amendment and satisfes rational basis review. Pp. 509–526. (a) SB1 is not subject to heightened scrutiny because it does not clas- sify on any bases that warrant heightened review. Pp. 510–522. (1) On its face, SB1 incorporates two classifcations: one based on age (allowing certain medical treatments for adults but not minors) and another based on medical use (permitting puberty blockers and hor- mones for minors to treat certain conditions but not to treat gender dysphoria, gender identity disorder, or gender incongruence). Classi- fcations based on age or medical use are subject to only rational basis 496 UNITED STATES v. SKRMETTI Syllabus review. See Massachusetts Bd. of Retirement v. Murgia, 427 U. S. 307 (per curiam); Vacco v. Quill, 521 U. S. 793. The plaintiffs argue that SB1 warrants heightened scrutiny because it relies on sex-based classifcations. But neither of the above classif- cations turns on sex. Rather, SB1 prohibits healthcare providers from administering puberty blockers or hormones to minors for certain medi- cal uses, regardless of a minor's sex. While SB1's prohibitions refer- ence sex, the Court has never suggested that mere reference to sex is suffcient to trigger heightened scrutiny. And such an approach would be especially inappropriate in the medical context, where some treat- ments and procedures are uniquely bound up in sex. The application of SB1, moreover, does not turn on sex. The law does not prohibit certain medical treatments for minors of one sex while allowing those same treatments for minors of the opposite sex. SB1 prohibits healthcare providers from administering puberty blockers or hormones to any minor to treat gender dysphoria, gender identity disor- der, or gender incongruence, regardless of the minor's sex; it permits providers to administer puberty blockers and hormones to minors of any sex for other purposes. And, while a State may not circumvent the Equal Protection Clause by writing in abstract terms, SB1 does not mask sex-based classifcations. Page Proof Pending Publication Finally, the Court rejects the plaintiffs' argument that, by design, SB1 enforces a government preference that people conform to expecta- tions about their sex. To start, any allegations of sex stereotyping are misplaced. True, a law that classifes on the basis of sex may fail heightened scrutiny if the classifcations rest on impermissible stereo- types. But where a law's classifcations are neither covertly nor overtly based on sex, the law does not trigger heightened review unless it was motivated by an invidious discriminatory purpose. No such argument has been raised here. And regardless, the statutory fndings on which SB1 is premised do not themselves evince sex-based stereotyping. Pp. 511–517. (2) SB1 also does not classify on the basis of transgender status. The Court has explained that a State does not trigger heightened consti- tutional 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, the Court held that a California insurance program that excluded from coverage certain disabilities resulting from pregnancy did not discriminate on the basis of sex. See id., at 486, 492–497. In reaching that holding, the Court explained that the program did not exclude any individual from beneft eligibility because of the individual's sex but rather “remove[d] one physical condition—pregnancy—from the list of compensable disabili- Cite as: 605 U. S. 495 (2025) 497 Syllabus ties.” Id., at 496, n. 20. The California insurance program, the Court explained, divided potential recipients into two groups: “pregnant women and nonpregnant persons.” Id., at 497, n. 20. Because women fell into both groups, the Court reasoned, the program did not discrimi- nate against women as a class. See id., at 496, and n. 20. The Court concluded that, even though only biological women can become preg- nant, not every legislative classifcation concerning pregnancy is a sex- based classifcation. Id., at 496, n. 20. As such, “[a]bsent a showing that distinctions involving pregnancy are mere pretexts designed to ef- fect an invidious discrimination against the members of one sex or the other, lawmakers are constitutionally free to include or exclude preg- nancy from the coverage of legislation . . . on any reasonable basis, just as with respect to any other physical condition.” Id., at 496–497, n. 20. By the same token, SB1 does not exclude any individual from medical treatments on the basis of transgender status. Rather, it removes one set of diagnoses—gender dysphoria, gender identity disorder, and gen- der incongruence—from the range of treatable conditions. SB1 divides minors into two groups: those seeking puberty blockers or hormones to treat the excluded diagnoses, and those seeking puberty blockers or hormones to treat other conditions. While the frst group includes only Page Proof Pending Publication transgender individuals, the second encompasses both transgender and nontransgender individuals. Thus, although only transgender individu- als seek treatment for gender dysphoria, gender identity disorder, and gender incongruence—just as only biological women can become preg- nant—there is a “lack of identity” between transgender status and the excluded diagnoses. Absent a showing that SB1's prohibitions are pre- texts designed to effect invidious discrimination against transgender in- dividuals, the law does not classify on the basis of transgender status. Pp. 517–519. (3) Finally, Bostock v. Clayton County, 590 U. S. 644, does not alter the Court's analysis. In Bostock, the Court held that an employer who fres an employee for being gay or transgender violates Title VII's pro- hibition on discharging an individual “because of ” their sex. See id., at 650–652, 654–659. The Court reasoned that Title VII's “because of ” test incorporates the traditional but-for causation standard, which di- rects courts “to change one thing at a time and see if the outcome changes.” Id., at 656. Applying that test, the Court held that, “[f]or an employer to discriminate against employees for being homosexual or transgender, the employer must intentionally discriminate against individual men and women in part because of sex.” Id., at 662. In such a case, the employer has penalized a member of one sex for a trait or action that it tolerates in members of the other. 498 UNITED STATES v. SKRMETTI Syllabus The Court declines to address whether Bostock's reasoning reaches beyond the Title VII context—unlike the employment discrimination at issue in Bostock, changing a minor's sex or transgender status does not alter the application of SB1. If a transgender boy seeks testosterone to treat gender dysphoria, SB1 prevents a healthcare provider from ad- ministering it to him. If his biological sex were changed from female to male, SB1 would still not permit him the hormones he seeks because he would lack a qualifying diagnosis. The transgender boy could re- ceive testosterone only if he had a permissible diagnosis (like a congeni- tal defect). And, if he had such a diagnosis, he could obtain the tes- tosterone regardless of his sex or transgender status. Under the reasoning of Bostock, neither his sex nor his transgender status is the but-for cause of his inability to obtain testosterone. Pp. 519–522. (b) SB1 satisfes rational basis review. Under that standard, the Court will uphold a statutory classifcation so long as there is “any rea- sonably conceivable state of facts that could provide a rational basis for the classifcation.” FCC v. Beach Communications, Inc., 508 U. S. 307, 313. SB1 clearly meets that standard of review. Tennessee deter- mined that administering puberty blockers or hormones to minors to treat gender dysphoria, gender identity disorder, or gender incongru- ence carries risks, including irreversible sterility, increased risk of dis- Page Proof Pending Publication ease and illness, and adverse psychological consequences. The legisla- ture found that minors lack the maturity to fully understand these consequences, that many individuals have expressed regret for undergo- ing such treatments as minors, and that the full effects of such treat- ments may not yet be known. At the same time, the State noted evi- dence that discordance between sex and gender can be resolved through less invasive approaches. SB1's age- and diagnosis-based classifcations are rationally related to these fndings and the State's objective of pro- tecting minors' health and welfare. The Court also declines the plaintiffs' invitation to second-guess the lines that SB1 draws. States have “wide discretion to pass legislation in areas where there is medical and scientifc uncertainty.” Gonzales v. Carhart, 550 U. S. 124, 163. Recent developments demonstrate the open questions that exist regarding basic factual issues before medical authorities and regulatory bodies in this area, underscoring the need for legislative fexibility. Pp. 522–525. (c) This case carries with it the weight of ferce scientifc and policy debates about the safety, effcacy, and propriety of medical treatments in an evolving feld. The Equal Protection Clause does not resolve these disagreements. The Court's role is not “to judge the wisdom, fairness, or logic” of SB1, Beach Communications, 508 U. S., at 313, but only to ensure that the law does not violate equal protection guarantees. It Cite as: 605 U. S. 495 (2025) 499 Syllabus does not. Questions regarding the law's policy are thus appropriately left to the people, their elected representatives, and the democratic process. P. 525. 83 F. 4th 460, affrmed. 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., fled a concurring opinion, post, p. 526. Barrett, J., fled a concurring opinion, in which Thomas, J., joined, post, p. 547. Alito, J., fled an opinion concurring in part and concurring in the judgment, post, p. 557. Sotomayor, J., fled a dissenting opinion, in which Jackson, J., joined in full, and in which Kagan, J., joined as to Parts I–IV, post, p. 578. Kagan, J., fled a dissenting opinion, post, p. 607. Solici tor General Prelogar argued the cause for the United States. With her on the briefs were Assistant At- torney General Clarke, Deputy Solicitor General Fletcher, Yaira Dubin, Bonnie I. Robin-Vergeer, and Barbara A. Schwabauer. Page Proof Pending Publication Chase B. Strangio argued the cause for respondents L. W. et al. urging vacatur. With him on the briefs were Joshua A. Block, James D. Esseks, Sruti J. Swaminathan, Ria Ta- bacco Mar, Louise Melling, Pratik A. Shah, Martine E. Cic- coni, Kristen E. Loveland, Cecillia D. Wang, David D. Cole, Lucas Cameron-Vaughn, Stella Yarbrough, Sasha Buchert, Jennifer C. Pizer, Camilla B. Taylor, Karen L. Loewy, Tara L. Borelli, Zach ZhenHe Tan, and T. James Salwen. J. Matthew Rice, Solicitor General of Tennessee, argued the cause for respondents Jonathan Skrmetti et al. With him on the brief were Jonathan Skrmetti, Attorney General, pro se, Whitney D. Hermandorfer, Steven J. Griffn, Gabriel Krimm, Assistant Solicitor General, Adam K. Mortara, Jef- frey M. Harris, and Cameron T. Norris.* *Briefs of amici curiae urging reversal were fled for the State of Cali- fornia et al. by Rob Bonta, Attorney General of California, Michael J. Mongan, Solicitor General, Julie Veroff and Samuel T. Harbourt, Deputy Solicitors General, Kathleen Boergers, Supervising Deputy Attorney Gen- eral, Nimrod Pitsker Elias, Sean McGuire, and Stephanie T. Yu, Deputy 500 UNITED STATES v. SKRMETTI Opinion of the Court 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. Attorneys General, and Alice X. Wang, Associate Deputy Solicitor Gen- eral, and by the Attorneys General for their respective jurisdictions as follows: Philip J. Weiser of Colorado, William Tong of Connecticut, Kath- leen Jennings of Delaware, Brian L. Schwalb of the District of Columbia, Anne E. Lopez of Hawaii, Kwame Raoul of Illinois, Aaron M. Frey of Maine, Anthony G. Brown of Maryland, Andrea Joy Campbell of Massa- chusetts, Dana Nessel of Michigan, Keith Ellison of Minnesota, Aaron D. Ford of Nevada, Matthew J. Platkin of New Jersey, Letitia James of New York, Ellen F. Rosenblum of Oregon, Michelle A. Henry of Pennsylvania, Peter F. Neronha of Rhode Island, Charity R. Clark of Vermont, and Robert W. Ferguson of Washington; for the American Bar Association by John P. Elwood, Andrew T. Tutt, Daniel Yablon, and William R. Bay; for the American Historical Association et al. by Kara N. Ingelhart; for the American Psychological Association et al. by Jessica Ring Amunson, De- Page Proof Pending Publication anne M. Ottaviano, and Howard S. Suskin; for Conservative Offcials et al. by Brian T. Burgess and Jesse Lempel; for the Constitutional Ac- countability Center by Elizabeth B. Wydra, Brianne J. Gorod, and David H. Gans; for the Disability Rights Education & Defense Fund et al. by Claudia Center; for Equality Florida et al. by Rachel G. Miller-Ziegler and J. Max Rosen; for Families with Transgender Children by Peter T. Barbur; for Foreign Non-Proft Organizations Advocating for the Rights of Transgender People by Andrew Rhys Davies, Charles C. Bridge, and Eric L. Hawkins; for the Genders & Sexualities Alliance Network et al. by Julia R. Lissner, Lynly S. Egyes, Shawn Thomas Meerkamper, Dale Melchert, Milo Inglehart, and Melissa L. Cizmorris; for the Giffords Law Center to Prevent Gun Violence et al. by Janice Mac Avoy, Esther Sanchez-Gomez, Leigh Rome, Douglas N. Letter, and Shira Lauren Feld- man; for GRACE et al. by Boris Bershteyn and Sean Madden; for inter- ACT: Advocates for Intersex Youth by Jonah M. Knobler and Alexander L. Chen; for Kentucky Plaintiffs et al. by Stephanie Schuster, Justin D. Weitz, Jordan D. Hershman, Shannon Minter, Christopher F. Stoll, Corey Shapiro, William E. Sharp, and Jennifer L. Levi; for Members of Congress by Conor Tucker; for Professors of Law et al. by Kathleen R. Hartnett; for TransParent et al. by Benjamin G. Bradshaw, Deanna M. Rice, Rachel Chung, T. Brandon Waddell, Sarah Brewerton-Palmer, Cyn- thia Cheng-Wun Weaver, and Peter E. Perkowski; for the Trevor Project Cite as: 605 U. S. 495 (2025) 501 Opinion of the Court I A An estimated 1.6 million Americans over the age of 13 identify as transgender, meaning that their gender identity et al. by Justin R. Rassi; for Yale Philosophers by Jessica Weisel, Anna- Rose Mathieson, and Amanda Shanor; for Dr. Erica E. Anderson, PhD, et al. by Samantha L. Chaifetz and Marie Bussey-Garza; for William Esk- ridge, Jr., et al. by Leslie Greathouse; for Elliot Page et al. by Sydney Duncan, Gabriel Arkles, Carmine D. Boccuzzi, Jr., and Howard S. Zelbo; and for 17 Healthcare Providers by Amelia T. R. Starr, James H. R. Win- dels, and Deborah S. Mazer. Briefs of amici curiae urging vacatur were fled for the American Academy of Pediatrics et al. by D. Jean Veta and William R. Isasi; for Experts on Gender Affrming Care by Craig Kon- noth; for Expert Researchers et al. by Alexander Shalom and Natalie J. Kraner; and for Legal Scholars et al. by Catherine E. Stetson and Kenneth Y. Choe. Briefs of amici curiae urging affrmance were fled for the State of Alabama by Steve Marshall, Attorney General, Edmund G. LaCour, Jr., Page Proof Pending Publication Solicitor General, and A. Barrett Bowdre, Principal Deputy Solicitor Gen- eral; for the State of Kentucky et al. by Russell Coleman, Attorney Gen- eral of Kentucky, Matthew F. Kuhn, Solicitor General, John H. Heyburn, Principal Deputy Solicitor General, and Daniel J. Grabowski, Assistant Solicitor General, by Tim Griffn, Attorney General of Arkansas, Nicholas J. Bronni, Solicitor General, and Dylan L. Jacobs, Deputy Solicitor Gen- eral, by Theodore E. Rokita, Attorney General of Indiana, James A. Barta, Solicitor General, and John M. Vastag, Deputy Attorney General, and by the Attorneys General for their respective States as follows: Treg Taylor of Alaska, Ashley Moody of Florida, Chris Carr of Georgia, Raúl Labra- dor of Idaho, Brenna Bird of Iowa, Kris Kobach of Kansas, Liz Murrill of Louisiana, Lynn Fitch of Mississippi, Austin Knudsen of Montana, Mi- chael T. Hilgers of Nebraska, Drew Wrigley of North Dakota, Dave Yost of Ohio, Gentner Drummond of Oklahoma, Alan Wilson of South Caro- lina, Marty Jackley of South Dakota, Sean Reyes of Utah, Jason Miyares of Virginia, Patrick Morrisey of West Virginia, and Bridget Hill of Wyo- ming; for the State of Missouri by Andrew Bailey, Attorney General, Joshua M. Divine, Solicitor General, Reed C. Dempsey, Deputy Solicitor General, and Peter F. Donohue, Assistant Attorney General; for the State of Texas by Ken Paxton, Attorney General, Charles K. Eldred, Brent Web- ster, First Assistant Attorney General, Ralph Molina, Deputy First As- sistant Attorney General, Austin Kinghorn, Deputy Attorney General, 502 UNITED STATES v. SKRMETTI Opinion of the Court 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 signifcant distress resulting from an in- and Johnathan Stone; for the Florida House of Representatives by David Axelman; for Gov. Greg Gianforte by Anita Y. Milanovich; for Gov. Henry Dargan McMaster et al. by Thomas A. Limehouse, Jr., Wm. Grayson Lambert, and Tyra S. McBride; for the Governor of Texas by Greg Ab- bott, pro se, James P. Sullivan, and Jason Bramow; for the Alliance De- fending Freedom by John J. Bursch, James A. Campbell, and Cody S. Barnett; for the America First Legal Foundation by Jonathan F. Mitchell and Gene P. Hamilton; for the American Civil Rights Project by Daniel I. Morenoff; for the American College of Pediatricians et al. by Gene C. Schaerr and Edward H. Trent; for the American Principles Project by Theodore M. Cooperstein and Craig L. Parshall; for America's Frontline Doctors et al. by David A. Dalia; for America's Future et al. by William J. Olson, Jeremiah L. Morgan, Joseph W. Miller, Kerry L. Morgan, J. Mark Brewer, and Patrick M. McSweeney; for Citizens for Self-Gover- nance by Rita M. Peters and Michael Farris; for Concerned Women for Page Proof Pending Publication America et al. by Christopher E. Mills; for the Defense of Freedom Insti- tute for Policy Studies by Donald A. Daugherty, Jr.; for Do No Harm by David H. Thompson and Brian W. Barnes; for the Ethics and Public Pol- icy Center by Eric N. Kniffn; for the Ethics and Religious Liberty Com- mission et al. by Jeffrey A. Hall and Ilya Shapiro; for the Family Action Council of Tennessee et al. by J. Thomas Smith; for the Family Research Council by Christopher E. Mills; for Fifty-six Physicians by Andrew D. Watkins and Edward M. Wenger; for the Frontline Policy Council et al. by Kristine L. Brown; for the Independent Council on Women's Sports et al. by William Bock III; for the Independent Women's Law Center by James M. Burnham, Sylvia May Mailman, and Emmett E. Robinson; for International Non-Proft Organizations Advocating for Families Impacted by Gender Dysphoria by Randall L. Wenger; for Liberty Counsel by Ma- thew D. Staver, Anita L. Staver, and Horatio G. Mihet; for the Manhattan Institute et al. by Ilya Shapiro; for the North Carolina Values Institute by Deborah J. Dewart and Tami Fitzgerald; for Our Duty–USA by Nicholas P. Miller; for Partners for Ethical Care et al. by Mary E. McAlister and Vernadette R. Broyles; for the Society for Evidence-Based Gender Medi- cine (SEGM) by Daniel J. Cragg; for State Legislators et al. by Trey Del- linger; for the United States Conference of Catholic Bishops et al. by Megan M. Wold; for Wisconsin Family Action et al. by Frederick W. Clay- brook, Jr., Steven W. Fitschen, and James A. Davids; for the Women's Cite as: 605 U. S. 495 (2025) 503 Opinion of the Court congruence between gender identity and biological sex. Left untreated, gender dysphoria may result in severe physi- cal and psychological harms. In 1979, the World Professional Association for Transgen- der Health (WPATH) (then known as the Harry Benjamin International Gender Dysphoria Association) published one of the frst sets of clinical guidelines for treating gender dys- phoria with sex transition treatments. See P. Walker et al., Standards of Care: The Hormonal and Surgical Sex Reas- signment of Gender Dysphoric Persons (1979), reprinted in 14 Archives of Sexual Behavior 79 (1985). The standards addressed two treatments in particular: hormonal sex reas- signment (the use of hormones to induce the development of physical characteristics of the opposite sex) and surgical sex reassignment (surgery of the genitalia and/or chest to ap- proximate the physical appearance of the opposite sex). See id., at 81, §§ 3.2–3.3. They recognized the extensive and sometimes irreversible consequences of hormonal therapy Page Proof Pending Publication and sex reassignment surgery and acknowledged that some Liberation Front by Elspeth B. Cypher; for Isabelle Ayala et al. by Joshua K. Payne and Jordan Campbell; for Joseph Burgo, PhD, et al. by Mitra N. Forouhar; for Christopher R. Green, pro se; for Kurt T. Lash by R. Trent McCotter; for Abigail Martinez by Kelly J. Shackelford, Jeffrey C. Mateer, David J. Hacker, and Jeremiah G. Dys. Briefs of amici curiae were fled for Advancing American Freedom et al. by J. Marc Wheat; for Citizens Defending Freedom by Jason C. Greaves; for the Claremont Institute's Center for Constitutional Jurispru- dence by John C. Eastman and Anthony T. Caso; for Clinical Practice Guideline Experts by Eugene E. Stearns; for Family Law and Constitu- tional Law Scholars by Brian R. Matsui and Kevin Barry, pro se; for the Larger Detransitioners Community et al. by Terry Lee Fowler; for the NAACP Legal Defense & Educational Fund, Inc., by Janai S. Nelson, Samuel Spital, Alexsis Johnson, Avatara A. Smith-Carrington, Molly M. Cain, Kacey Mordecai, and Robert Niles-Weed; for Scholars of Philosophy et al. by Dean R. Broyles; for Williams Institute Scholars by David S. Flugman and Corey Stoughton; for Women's Declaration International USA by Kara Dansky; for James F. Blumstein, pro se; and for Max Laz- zara by Sean P. Gates. 504 UNITED STATES v. SKRMETTI Opinion of the Court individuals who undergo reassignment procedures later re- gret their decision to do so. See id., at 83, 85–86, §§ 4.1.1– 4.1.3, 4.4.2–4.4.3, 4.5.1. Among other things, the standards of care provided that hormonal and surgical sex reassign- ment treatments should be administered only to adults. See id., at 89, § 4.14.4. In 1998, WPATH revised its standards of care to permit healthcare professionals to administer puberty blockers (de- signed to delay the development of physical sex characteris- tics) and hormones to minors in “rar[e]” circumstances. S. Levine et al., The Standards of Care for Gender Identity Disorders (5th ed. 1998), reprinted in 11 J. Psychology & Human Sexuality 1, 20 (1999). Today, the standards discuss a range of factors regarding the provision of such treatments to minors. E. Coleman et al., Standards of Care for the Health of Transgender and Gender Diverse People, Version 8, 23 Int'l J. Transgender Health S1, S65–S66 (2022). The Page Proof Pending Publication current standards recognize known risks associated with the provision of sex transition treatments to adolescents, includ- ing potential adverse effects on fertility and the possibility that an adolescent will later wish to detransition. See id., at S47, S57, S61–S62. They further state that there is “lim- ited data on the optimal timing” of sex transition treatments or “the long-term physical, psychological, and neurodevelop- mental outcomes in youth,” id., at S65, and note that “[o]ur understanding of gender identity development in adolescence is continuing to evolve,” id., at S44. In recent years, the number of minors requesting sex tran- sition treatments has increased. See 2 App. 644, 827–828. This increase has corresponded with rising debates regard- ing the relative risks and benefts of such treatments. Com- pare, e. g., Brief for State of California et al. as Amici Curiae 1–13, with Brief for Alabama as Amicus Curiae 1–9. In the last three years, more than 20 States have enacted laws ban- ning the provision of sex transition treatments to minors, while two have enacted near total bans. Cite as: 605 U. S. 495 (2025) 505 Opinion of the Court Meanwhile, health authorities in a number of European countries have raised signifcant concerns regarding the po- tential harms associated with using puberty blockers and hormones to treat transgender minors. In 2020, Finland's Council for Choices in Health Care found that “gender reas- signment of minors is an experimental practice” and that “the reliability of the existing studies” is “highly uncertain.” 2 App. 583–584 (alterations omitted); see id., at 715–722, 727–729. That same year, England's National Institute for Health and Care Excellence published reports fnding that the evidence for using puberty blockers to treat transgender adolescents is of “very low certainty” and that the long-term risks associated with using hormones to treat adolescents with gender dysphoria are “largely unknown.” Id., at 588– 589. In 2022, Sweden's National Board of Health and Wel- fare found that “the evidence on treatment effcacy and safety is still insuffcient and inconclusive” and that the “risks” of puberty blockers and hormones “currently out- Page Proof Pending Publication weigh the possible benefts.” 1 id., at 339–340; see 2 id., at 584–587. And in 2023, the Norwegian Healthcare Investiga- tion Board concluded that the “research-based knowledge” for hormonal sex transition treatments for minors is “insuf- fcient,” while the “long-term effects are little known.” 1 id., at 341–342. B In March 2023, Tennessee joined the growing number of States restricting sex transition treatments for minors by enacting the Prohibition on Medical Procedures Performed on Minors Related to Sexual Identity, S. B. 1, 113th Gen. Assem., 1st Extra. Sess.; Tenn. Code Ann. § 68–33–101 et seq. (SB1). While the State's legislature acknowledged that dis- cordance between a minor's gender identity and biological sex can cause “discomfort or distress,” § 68–33–101(c), it identifed concerns regarding the use of puberty blockers and hormones to treat gender dysphoria in minors. In particu- lar, the legislature found that such treatments “can lead to 506 UNITED STATES v. SKRMETTI Opinion of the Court the minor becoming irreversibly sterile, having increased risk of disease and illness, or suffering from adverse and sometimes fatal psychological consequences,” § 68–33–101(b), and that minors “lack the maturity to fully understand and appreciate” these consequences and may later regret under- going the treatments, § 68–33–101(h). The legislature fur- ther found that sex transition treatments were “being per- formed on and administered to minors in th[e] state with rapidly increasing frequency,” § 68–33–101(g), notwithstand- ing the fact that the full range of harmful effects associated with the treatments were likely not yet known, see § 68–33– 101(b). The legislature also noted that guidelines regarding sex transition treatments for minors had “changed substan- tially in recent years,” § 68–33–101(g), and that health au- thorities in Sweden, Finland, and the United Kingdom had “placed severe restrictions” on such treatments after deter- mining that there was “no evidence” that their benefts out- Page Proof Pending Publication weigh their risks, § 68–33–101(e); see supra, at 505. Finally, the legislature determined that there is evidence that gender dysphoria “can be resolved by less invasive approaches that are likely to result in better outcomes.” § 68–33–101(c). SB1 responds to these concerns by banning the use of cer- tain medical procedures for treating transgender minors. In 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]rescrib- ing, administering, or dispensing any puberty blocker or hor- mone,” § 68–33–102(5), for the purpose of (1) “[e]nabling a minor to identify with, or live as, a purported identity incon- sistent with the minor's sex,” or (2) “[t]reating purported discomfort or distress from a discordance between the mi- nor's sex and asserted identity,” § 68–33–103(a)(1). Among other things, these prohibitions are intended to “protec[t] mi- nors from physical and emotional harm” by “encouraging mi- nors to appreciate,” rather than “become disdainful of,” their sex. § 68–33–101(m). Cite as: 605 U. S. 495 (2025) 507 Opinion of the Court SB1 is limited in two relevant ways. First, SB1 does not restrict the administration of puberty blockers or hormones to individuals 18 and over. § 68–33–102(6). Second, SB1 does not ban fully the administration of such drugs to minors. A healthcare provider may administer puberty blockers or hormones to treat a minor's congenital defect, precocious (or early) puberty, disease, or physical injury. § 68–33–103(b) (1)(A). The law defnes the term “[c]ongenital defect” to in- clude an “abnormality present in a minor that is inconsistent with the normal development of a human being of the minor's sex,” § 68–33–102(1), but excludes from the defnitions of “[c]ongenital defect” and “disease” “gender dysphoria, gen- der identity disorder, [and] gender incongruence,” §§ 68–33– 102(1), 68–33–103(b)(2). SB1 contains three primary enforcement mechanisms. The law authorizes Tennessee's attorney general to bring against any person who knowingly violates SB1 an action “to enjoin further violations, to disgorge any profts received due Page Proof Pending Publication to the medical procedure, and to recover a civil penalty of [$25,000] per violation.” § 68–33–106(b). SB1 further per- mits the relevant state regulatory authorities to discipline healthcare providers who violate the law's prohibitions. § 68–33–107. Finally, SB1 creates a private right of action that enables an injured minor or nonconsenting parent of an injured minor to sue a healthcare provider for violating the law. § 68–33–105. C Three transgender minors, their parents, and a doctor (plaintiffs) brought a pre-enforcement challenge to SB1. Among other things, the plaintiffs asserted that SB1 violates the Equal Protection Clause of the Fourteenth Amendment. They moved for a preliminary injunction preventing the law's bans on sex transition treatments for minors from going into effect. The United States intervened under 42 U. S. C. § 2000h–2, which authorizes the Federal Government to intervene in a private equal protection suit “if the Attor- 508 UNITED STATES v. SKRMETTI Opinion of the Court ney General certifes that the case is of general public impor- tance.” See Memorandum Opinion and Order in No. 23–cv– 00376 (MD Tenn., May 16, 2023), ECF Doc. 108. The District Court partially enjoined enforcement of SB1's prohibitions. See L. W. v. Skrmetti, 679 F. Supp. 3d 668, 677 (MD Tenn. 2023). The court concluded that the plaintiffs lacked standing to challenge the law's ban on sex transition surgery for minors. Id., at 681–682. But the court held, as relevant, that the United States and plaintiffs were likely to succeed on their equal protection challenge to the law's prohibitions on puberty blockers and hormones. Id., at 682– 712. The court found that transgender individuals consti- tute a quasi-suspect class, that SB1 discriminates on the basis of sex and transgender status, and that SB1 was un- likely to survive intermediate scrutiny. Id., at 686–687, 698, 712. Having concluded that SB1 was likely unconstitutional on its face, the District Court issued a statewide injunction Page Proof Pending Publication enjoining enforcement of all provisions of SB1 except for the private right of action and the law's ban on sex transition surgery. See id., at 680– 681, 716–718. Tennessee ap- pealed, and the Sixth Circuit stayed the preliminary injunc- tion pending appeal. L. W. v. Skrmetti, 83 F. 4th 460, 469 (CA6 2023). The Sixth Circuit reversed. As relevant, the Sixth Cir- cuit held that the United States and plaintiffs were unlikely to succeed on the merits of their equal protection claim. See id., at 479–489. The court frst found that SB1 does not clas- sify on the basis of sex because the law “regulate[s] sex- transition treatments for all minors, regardless of sex,” by prohibiting all minors from “receiv[ing] puberty blockers or hormones or surgery in order to transition from one sex to another.” Id., at 480. The court next declined to recognize transgender individuals as a suspect class, fnding that trans- gender individuals are neither politically powerless nor a dis- crete group defned by obvious, immutable, or distinguish- ing characteristics. Id., at 486–487. Finally, the court Cite as: 605 U. S. 495 (2025) 509 Opinion of the Court concluded that the United States and plaintiffs had failed to establish that animus toward transgender individuals as a class was the operative force behind SB1. See id., at 487– 488. The Sixth Circuit held that SB1 was subject to and survived rational basis review, fnding that Tennessee had offered “considerable evidence” regarding the risks associ- ated with the banned medical treatments and the faws in existing research. Id., at 489. Judge White dissented. Judge White would have held that the United States and plaintiffs were likely to succeed on the merits of their equal protection claim. Id., at 498. In her view, SB1 triggered heightened scrutiny because it “facially discriminate[s] based on a minor's sex as assigned at birth and on a minor's failure to conform with societal expectations concerning that sex.” Ibid. Judge White would have held that Tennessee had failed to “show an ex- ceeding[ly] persuasive justifcation or close means-ends ft” for the law's sex-based classifcations. Ibid. Page Proof Pending Publication We granted certiorari to decide whether SB1 violates the Equal Protection Clause of the Fourteenth Amendment.1 602 U. S. 1037 (2024). II The Fourteenth Amendment's command that no State shall “deny to any person within its jurisdiction the equal protection of the laws,” U. S. Const., Amdt. 14, § 1, “must coexist with the practical necessity that most legislation clas- sifes for one purpose or another, with resulting disadvan- tage to various groups or persons,” Romer v. Evans, 517 U. S. 620, 631 (1996). We have reconciled the principle of 1 Following oral argument, the United States submitted a letter to the Court representing that the United States “has now determined that SB1 does not deny equal protection on account of sex or any other characteris- tic” but “believes that the confuence of several factors counsels against seeking to dismiss its case in this Court.” Letter from C. Gannon, Deputy Solicitor General, to S. Harris, Clerk of Court (Feb. 7, 2025). The plain- tiffs remain adverse to the state respondents. 510 UNITED STATES v. SKRMETTI Opinion of the Court equal protection with the reality of legislative classifcation by holding that, “if a law neither burdens a fundamental right nor targets a suspect class, we will uphold the legisla- tive classifcation so long as it bears a rational relation to some legitimate end.” Ibid. We generally afford such laws “wide latitude” under this rational basis review, acknowledg- ing that “the Constitution presumes that even improvident decisions will eventually be rectifed by the democratic proc- esses.” Cleburne v. Cleburne Living Center, Inc., 473 U. S. 432, 440 (1985). Certain legislative classifcations, however, prompt height- ened review. For example, laws that classify on the basis of race, alienage, or national origin trigger strict scrutiny and will pass constitutional muster “only if they are suitably tai- lored to serve a compelling state interest.” Ibid. We have similarly held that sex-based classifcations warrant height- ened scrutiny. See United States v. Virginia, 518 U. S. 515, 533 (1996). While our precedent does not make sex a “pro- Page Proof Pending Publication scribed classifcation,” ibid., we have explained that sex “generally provides no sensible ground for differential treat- ment,” Cleburne, 473 U. S., at 440, and that sex-based lines too often refect stereotypes or overbroad generalizations about the differences between men and women, see Sessions v. Morales-Santana, 582 U. S. 47, 62 (2017). We accordingly subject laws containing sex-based classifcations to interme- diate scrutiny, under which the State must show that the “classifcation serves important governmental objectives and that the discriminatory means employed are substantially re- lated to the achievement of those objectives.” Virginia, 518 U. S., at 533 (internal quotation marks omitted). A We are asked to decide whether SB1 is subject to height- ened scrutiny under the Equal Protection Clause. We hold it is not. SB1 does not classify on any bases that warrant heightened review. Cite as: 605 U. S. 495 (2025) 511 Opinion of the Court 1 On its face, SB1 incorporates two classifcations. First, SB1 classifes on the basis of age. Healthcare providers may administer certain medical treatments to individuals ages 18 and older but not to minors. Second, SB1 classifes on the basis of medical use. Healthcare providers may administer puberty blockers or hormones to minors to treat certain con- ditions but not to treat gender dysphoria, gender identity disorder, or gender incongruence. Classifcations that turn on age or medical use are subject to only rational basis re- view. See Massachusetts Bd. of Retirement v. Murgia, 427 U. S. 307, 312–314 (1976) (per curiam) (rational basis review applies to age-based classifcation); Vacco v. Quill, 521 U. S. 793, 799–808 (1997) (state laws outlawing assisted suicide “neither infringe fundamental rights nor involve suspect classifcations”). The plaintiffs argue that SB1 warrants heightened scru- Page Proof Pending Publication tiny because it relies on sex-based classifcations. See Brief for Respondents in Support of Petitioner 20– 37. We disagree. Neither of the above classifcations turns on sex. Rather, SB1 prohibits healthcare providers from administering pu- berty blockers and hormones to minors for certain medical uses, regardless of a minor's sex. Cf. Vacco, 521 U. S., at 800 (“On their faces, neither New York's ban on assisting suicide nor its statutes permitting patients to refuse medical treatment treat anyone differently from anyone else or draw any distinctions between persons. Everyone, regardless of physical condition, is entitled, if competent, to refuse un- wanted lifesaving medical treatment; no one is permitted to assist a suicide.”). The plaintiffs resist this conclusion, arguing that SB1 cre- ates facial sex-based classifcations by defning the prohibited medical care based on the patient's sex. See Brief for Re- spondents in Support of Petitioner 22. This argument takes two forms. At times, the plaintiffs suggest that SB1 classi- 512 UNITED STATES v. SKRMETTI Opinion of the Court fes on the basis of sex because its prohibitions reference sex. Alternatively, the plaintiffs contend that SB1 works a sex- based classifcation because application of the law turns on sex. Neither argument is persuasive. This Court has never suggested that mere reference to sex is suffcient to trigger heightened scrutiny. See, e. g., Tuan Anh Nguyen v. INS, 533 U. S. 53, 64 (2001) (“The issue is not the use of gender specifc terms instead of neutral ones. Just as neutral terms can mask discrimination that is unlaw- ful, gender specifc terms can mark a permissible distinc- tion.”). Such an approach, moreover, would be especially inappropriate in the medical context. Some medical treat- ments and procedures are uniquely bound up in sex. The Food and Drug Administration itself recognizes that “[r]e- search has shown that biological differences between men and women (differences due to sex chromosome or sex hor- mones) may contribute to variations seen in the safety and Page Proof Pending Publication effcacy of drugs, biologics, and medical devices.” FDA, Sex as a Biological Variable (Jan. 30, 2025) (online source ar- chived at https://www.supremecourt.gov). Indeed, the agency frequently approves drugs for use by only one sex. See, e. g., FDA, FDA in Brief: FDA Encourages Inclusion of Male Patients in Breast Cancer Clinical Trials (Aug. 26, 2019) (online source archived at https://www.supremecourt .gov) (“many” breast cancer treatments approved for women only); FDA, FDA Approves Second Drug To Prevent HIV Infection as Part of Ongoing Efforts To End the HIV Epi- demic (Oct. 3, 2019) (online source archived at https://www. supremecourt.gov) (drug to prevent HIV not approved for women). In the medical context, the mere use of sex-based language does not sweep a statute within the reach of heightened scrutiny. We also reject the argument that the application of SB1 turns on sex. The plaintiffs and the dissent contend that an adolescent whose biological sex is female cannot receive puberty blockers or testosterone to live and present as a Cite as: 605 U. S. 495 (2025) 513 Opinion of the Court male, but an adolescent whose biological sex is male can, while an adolescent whose biological sex is male cannot re- ceive puberty blockers or estrogen to live and present as a female, but an adolescent whose biological sex is female can. See Brief for Respondents in Support of Petitioner 22; post, at 587–591 (Sotomayor, J., dissenting). So conceived, they argue, SB1 prohibits certain treatments for minors of one sex while allowing those same treatments for minors of the opposite sex. The plaintiffs and the dissent, however, contort the mean- ing of the term “medical treatment.” Notably absent from their framing is a key aspect of any medical treatment: the underlying medical concern the treatment is intended to ad- dress. The Food and Drug Administration approves drugs and requires that they be labeled for particular indications— the diseases or conditions that they treat, prevent, mitigate, diagnose, or cure. See 21 CFR §§ 201.57(c)(2), 314.50(a)(1) Page Proof Pending Publication (2024). Different drugs can be used to treat the same thing (would you like Advil or Tylenol for your headache?), and the same drug can treat different things (take DayQuil to ease your cough, fever, sore throat, and/or minor aches and pains). For the term “medical treatment” to make sense of these various combinations, it must necessarily encompass both a given drug and the specifc indication for which it is being administered. See Brief for Respondents in Support of Petitioner 5 (noting that “treatments” for adolescents with gender dysphoria include “puberty-delaying medication and hormone therapy” (emphasis added)). When properly understood from the perspective of the in- dications that puberty blockers and hormones treat, SB1 clearly does not classify on the basis of sex. Both puberty blockers and hormones can be used to treat certain overlap- ping indications (such as gender dysphoria), and each can be used to treat a range of other conditions. Id., at 6–7. These combinations of drugs and indications give rise to var- ious medical treatments. When, for example, a transgender 514 UNITED STATES v. SKRMETTI Opinion of the Court boy (whose biological sex is female) takes puberty blockers to treat his gender incongruence, he receives a different medical treatment than a boy whose biological sex is male who takes puberty blockers to treat his precocious puberty.2 SB1, in turn, restricts which of these medical treatments are available to minors: Under SB1, a healthcare provider may administer puberty blockers or hormones to any minor to treat a congenital defect, precocious puberty, disease, or physical injury, Tenn. Code Ann. § 68–33–103(b)(1)(A); a healthcare provider may not administer puberty blockers or hormones to any minor to treat gender dysphoria, gender identity disorder, or gender incongruence, see §§ 68–33– 102(1), 68–33–103(a)(1), (b)(2). The application of that prohi- bition does not turn on sex. Of course, a State may not circumvent the Equal Protec- tion Clause by writing in abstract terms. See Personnel Administrator of Mass. v. Feeney, 442 U. S. 256, 274 (1979) Page Proof Pending Publication (explaining that both overt and covert sex-based classifca- tions are subject to heightened review). The antimiscege- nation law that this Court struck down in Loving v. Vir- ginia, 388 U. S. 1 (1967), would not have shed its race-based classifcation had it, for example, prohibited “any person from marrying an individual of a different race.” Such a law would still have turned on a race-based classifcation: It would have prohibited Mildred Jeter (a black woman) from marrying Richard Loving (a white man), while permitting a white woman to do so. The law, in other words, would still “proscribe generally accepted conduct if engaged in by mem- bers of different races.” Id., at 11. Here, however, SB1 does not mask sex-based classifca- tions. For reasons we have explained, the law does not pro- 2 We use “transgender boy” to refer to an individual whose biological sex is female but who identifes as male, and “transgender girl” to refer to an individual whose biological sex is male but who identifes as female. Cite as: 605 U. S. 495 (2025) 515 Opinion of the Court hibit conduct for one sex that it permits for the other. Under SB1, no minor may be administered puberty blockers or hormones to treat gender dysphoria, gender identity dis- order, or gender incongruence; minors of any sex may be administered puberty blockers or hormones for other purposes. Nor are we persuaded that SB1's prohibition on the pre- scription of puberty blockers and hormones to “[e]nabl[e] a minor to identify with, or live as, a purported identity incon- sistent with the minor's sex” or to “[t]rea[t] purported dis- comfort or distress from a discordance between the minor's sex and asserted identity,” Tenn. Code Ann. § 68–33–103(a), refects a sex-based classifcation, contra, post, at 587–591 (opinion of Sotomayor, J.). In the dissent's view, this lan- guage “plainly classifes on the basis of sex” because it “turns on inconsistency with a protected characteristic.” Post, at 588. The dissent analogizes to a hypothetical law that “pro- Page Proof Pending Publication hibit[s] minors from attending any services, rituals, or assem- blies if done for the purpose of allowing the minor to identify with a purported identity inconsistent with the minor's reli- gion.” Ibid. (internal quotation marks omitted; emphasis deleted). Such a law, the dissent argues, would plainly clas- sify on the basis of religion. “Whether the law prohibits a minor from attending any particular religious service turns on the minor's religion: A Jewish child can visit a synagogue but not a church, while a Christian child can attend church but not the synagogue.” Ibid. But a prohibition on the prescription of puberty blockers and hormones to “[e]nabl[e] a minor to identify with, or live as, a purported identity inconsistent with the minor's sex,” Tenn. Code Ann. § 68–33–103(a)(1), is simply a prohibition on the prescription of puberty blockers and hormones to treat gender dysphoria, gender identity disorder, or gender incon- gruence. A law prohibiting attendance at a religious serv- ice “inconsistent with” the attendee's religion may trigger 516 UNITED STATES v. SKRMETTI Opinion of the Court heightened scrutiny. A law prohibiting the administration of specifc drugs for particular medical uses does not. See Vacco, 521 U. S., at 799–808. Finally, we reject the plaintiffs' argument that, “by design, SB1 enforces a government preference that people conform to expectations about their sex.” Brief for Respondents in Support of Petitioner 23. The plaintiffs note that SB1's statutory fndings state that Tennessee has a compelling in- terest in “encouraging minors to appreciate their sex” and in prohibiting medical care “that might encourage minors to become disdainful of their sex.” Ibid. (quoting Tenn. Code Ann. § 68–33–101(m)). They argue that these fndings re- veal that the law operates to force conformity with sex. See Brief for Respondents in Support of Petitioner 23; see also id., at 52 (“SB1's purpose is . . . to force . . . boys and girls to look and live like boys and girls.” (internal quotation marks omitted)). Page Proof Pending Publication To start, the plaintiffs' allegations of sex stereotyping are misplaced. True, a law that classifes on the basis of sex may fail heightened scrutiny if the classifcations rest on im- permissible stereotypes. See J. E. B. v. Alabama ex rel. T. B., 511 U. S. 127, 139, n. 11 (1994). But where a law's classifcations are neither covertly nor overtly based on sex, contrast, e. g., post, at 589–590, n. 8 (opinion of Sotomayor, J.) (referencing a hypothetical requirement that all children wear “sex-consistent clothing”), we do not subject the law to heightened review unless it was motivated by an invidious discriminatory purpose, see Personnel Administrator of Mass., 442 U. S., at 271–274; Arlington Heights v. Metropoli- tan Housing Development Corp., 429 U. S. 252, 264–266 (1977). No such argument has been raised here. See Tr. of Oral Arg. 57–59. Regardless, the statutory fndings to which the plaintiffs point do not themselves evince sex-based stereotyping. The plaintiffs fail to note that Tennessee also proclaimed a “legit- imate, substantial, and compelling interest in protecting mi- Cite as: 605 U. S. 495 (2025) 517 Opinion of the Court nors from physical and emotional harm.” Tenn. Code Ann. § 68–33–101(m). And they similarly fail to acknowledge that Tennessee found that the prohibited medical treatments are experimental, can lead to later regret, and are associated with harmful—and sometimes irreversible—risks. §§ 68– 33–101(b)–(e), (h). Tennessee's stated interests in “encour- aging minors to appreciate their sex” and in prohibiting med- ical care “that might encourage minors to become disdainful of their sex,” § 68–33–101(m), simply refect the State's con- cerns regarding the use of puberty blockers and hormones to treat gender dysphoria, gender identity disorder, and gender incongruence, see Brief for Respondents 26–27 (“Given high desistance rates among youth and the tragic `regret' of de- transitioners, it was not improper to conclude that kids bene- ft from additional time to `appreciate their sex' before em- barking on body-altering paths. Nor is it improper for the State to protect minors from procedures that `encourage them to become disdainful of their sex'—and thus at risk for Page Proof Pending Publication serious psychiatric conditions.” (citations and alterations omitted)); L. W., 83 F. 4th, at 485 (“A concern about poten- tially irreversible medical procedures for a child is not a form of stereotyping.”). 2 The plaintiffs separately argue that SB1 warrants height- ened scrutiny because it discriminates against transgender individuals, who the plaintiffs assert constitute a quasi- suspect class. See Brief for Respondents in Support of Peti- tioner 37–38. This Court has not previously held that trans- gender individuals are a suspect or quasi-suspect class. And this case, in any event, does not raise that question be- cause SB1 does not classify on the basis of transgender sta- tus. As we have explained, SB1 includes only two classif- cations: healthcare providers may not administer puberty blockers or hormones to minors (a classifcation based on age) to treat gender dysphoria, gender identity disorder, or gen- der incongruence (a classifcation based on medical use). 518 UNITED STATES v. SKRMETTI Opinion of the Court The plaintiffs do not argue that the frst classifcation turns on transgender status, and our case law forecloses any such argument as to the second. We have explained that a State does not trigger height- ened constitutional scrutiny by regulating a medical proce- dure that only one sex can undergo unless the regulation is a mere pretext for invidious sex discrimination. In Gedul- dig v. Aiello, 417 U. S. 484 (1974), for example, we held that a California insurance program that excluded from coverage certain disabilities resulting from pregnancy did not discrim- inate on the basis of sex. See id., at 486, 492–497. In reaching that holding, we explained that the program did not exclude any individual from beneft eligibility because of the individual's sex but rather “remove[d] one physical condi- tion—pregnancy—from the list of compensable disabilities.” Id., at 496, n. 20. We observed that the “lack of identity” between sex and the excluded pregnancy-related disabilities Page Proof Pending Publication became “clear upon the most cursory analysis.” Id., at 497, n. 20. The California insurance program, we explained, di- vided potential recipients into two groups: “pregnant women and nonpregnant persons.” Ibid. Because women fell into both groups, the program did not discriminate against women as a class. See id., at 496, and n. 20. We thus con- cluded that, even though only biological women can become pregnant, not every legislative classifcation concerning pregnancy is a sex-based classifcation. Id., at 496, n. 20. As such, “[a]bsent a showing that distinctions involving preg- nancy are mere pretexts designed to effect an invidious dis- crimination against the members of one sex or the other, lawmakers are constitutionally free to include or exclude pregnancy from the coverage of legislation . . . on any reason- able basis, just as with respect to any other physical condi- tion.” Id., at 496–497, n. 20. By the same token, SB1 does not exclude any individual from medical treatments on the basis of transgender status but rather removes one set of diagnoses—gender dysphoria, Cite as: 605 U. S. 495 (2025) 519 Opinion of the Court 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 hor- mones 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 transgen- der individuals seek puberty blockers and hormones for the excluded diagnoses, the frst group includes only transgender individuals; the second group, in contrast, encompasses both transgender and nontransgender individuals. Thus, al- though only transgender individuals seek treatment for gen- der dysphoria, gender identity disorder, and gender incon- gruence—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 circum- Page Proof Pending Publication stances, we decline to fnd that SB1's prohibitions on the use of puberty blockers and hormones exclude any individuals on the basis of transgender status.3 3 Finally, Bostock v. Clayton County, 590 U. S. 644 (2020), does not alter our analysis. In Bostock, we held that an em- 3 The dissent argues that our analysis “may well suggest that a law depriving all individuals who `have ever, or may someday, menstruate' of access to health insurance would be sex neutral merely because not all women menstruate.” Post, at 600 (opinion of Sotomayor, J.). But such a law is different from both SB1 and the law at issue in Geduldig. As we have explained, SB1 regulates certain medical treatments, see Tenn. Code Ann. § 68–33–103(a)(1); Geduldig involved a state disability insurance sys- tem that excluded certain pregnancy-related disabilities from coverage, see 417 U. S., at 487–489. The dissent's hypothetical law, in contrast, does not regulate a class of treatments or conditions. Rather, it regulates a class of persons identifed on the basis of a specifed characteristic. Nei- ther our analysis nor Geduldig speaks to a law that classifes on such a basis. 520 UNITED STATES v. SKRMETTI Opinion of the Court ployer who fres an employee for being gay or transgender violates Title VII's prohibition on discharging an individual “because of ” their sex. See id., at 650–652, 654–659. We reasoned that Title VII's “because of ” test incorporates the traditional but-for causation standard, which “directs us to change one thing at a time and see if the outcome changes. If it does, we have found a but-for cause.” Id., at 656. Applying that test, we held that, “[f]or an employer to dis- criminate against employees for being homosexual or trans- gender, the employer must intentionally discriminate against individual men and women in part because of sex.” Id., at 662. In such a case, the employer has penalized a member of one sex for a trait or action that it tolerates in members of the other. Ibid. The plaintiffs urge us to apply Bostock's reasoning to this case. In their view, SB1 violates the Equal Protection Clause because it prohibits a minor whose biological sex is Page Proof Pending