The Supreme Court wades into the transgender healthcare debate.

I’m Isaac Saul, and this is Tangle: an independent, nonpartisan, subscriber-supported politics newsletter that summarizes the best arguments from across the political spectrum on the news of the day — then “my take.”

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Today’s read: 16 minutes.

This Friday.

Two weeks ago, we promised a piece from our newest team member — Editor-at-Large Kmele Foster — on America’s racial reckoning. We postponed that essay to cover Israel’s attack on Iran and publish Editorial Fellow Hunter Casperson’s piece on genetic testing, but it's coming this Friday!

Quick hits.

1. President Donald Trump announced that Israel and Iran had accepted a ceasefire proposal, which began on Tuesday. However, both countries accused the other of violating the ceasefire after it went into effect, and President Trump sharply criticized both sides for not abiding by the terms. (The latest)
2. Iran launched a missile attack against a U.S. military base in Qatar in retaliation for Saturday’s strikes on Iranian nuclear facilities. No casualties were reported, and air defenses intercepted most of the missiles. (The attack) 
3. The Supreme Court stayed a lower court’s order that noncitizens set to be deported to a country other than their home country must be given advance notice of their destination. (The ruling)
4. A series of Russian drone and missile attacks on Kyiv killed 10 people and injured dozens, according to Ukrainian officials. (The attacks)
5. In testimony before the House Financial Services Committee on Tuesday, Federal Reserve Chair Jerome Powell told lawmakers that the central bank will not rush to cut interest rates as it assesses the effects of tariffs on the economy. (The remarks)

Today’s topic.

United States v. Skrmetti. On Wednesday, the Supreme Court voted 6–3 along ideological lines to uphold Tennessee’s ban on certain treatments for transgender minors. The ruling rejected an argument brought by three transgender teens, their parents and a Memphis doctor that the law violates the Constitution’s Equal Protection Clause and discriminates on the basis of sex, which requires stricter scrutiny than the standard applied by a federal appeals court that previously upheld the law.

Back up: In 2023, Tennessee’s SB1 went into effect, banning surgical procedures and the administration of puberty blockers or hormones for purposes of “enabling a minor to identify with, or live as, a purported identity inconsistent with the minor's sex.” After the plaintiffs’ initial challenge, a federal judge issued a temporary injunction on key parts of the law, finding that it likely violated the First and Fourteenth Amendments. However, the U.S. Court of Appeals for the 6th Circuit reversed that ruling, evaluating the law under a “rational basis” review that only assesses whether a law is rationally related to a legitimate government interest. The Supreme Court agreed to hear the case in June 2024.

The Biden Justice Department joined the plaintiffs in their challenge, arguing that the law discriminates by sex because it allows everyone except transgender minors access to puberty blockers and hormones. Then, in February, the Trump administration withdrew from the case, saying that “the new administration would not have intervened to challenge SB1 — let alone sought this court’s review of the court of appeals’ decision reversing the preliminary injunction against SB1.”

We covered oral arguments in the case in December 2024.

Writing for the majority, Chief Justice John Roberts rejected key tenets of the challengers’ arguments. Roberts noted the “fierce scientific and policy debates” about these treatments but said, “SB1 clearly does not classify on the basis of sex. Both puberty blockers and hormones can be used to treat certain overlapping indications (such as gender dysphoria), and each can be used to treat a range of other conditions.” Furthermore, the chief justice held that SB1 does not “classify on the basis of transgender status” because it does not exclude minors from certain treatments on the basis of their transgender identity. Instead, he wrote, “it removes one set of diagnoses — gender dysphoria, gender identity disorder, and gender incongruence — from the range of treatable conditions.” 

Justice Clarence Thomas wrote a concurring opinion in which he repudiated the scientific and medical sources cited by the plaintiffs in their effort to establish a “consensus” on transgender care for minors. “They have surreptitiously compromised their medical recommendations to achieve political ends,” Thomas wrote. Justice Amy Coney Barrett also penned a concurring opinion, writing that “transgender status is not marked by the same sort of ‘obvious, immutable, or distinguishing characteristics’ as race or sex.”

Justice Sonia Sotomayor dissented. “Tennessee’s law expressly classifies on the basis of sex and transgender status,” Sotomayor wrote, which she said subjects the law to intermediate scrutiny, a stricter standard than a rational basis review. 

Today, we’ll share arguments from the right and left about the court’s ruling, followed by my take.

What the right is saying.

• The right welcomes the ruling and scores it as a major win for protecting children.
• Some question the plaintiffs’ legal strategy in bringing the case.
• Others say the court left some key questions unresolved. 

In The Hill, Jim Campbell wrote the “Supreme Court’s Skrmetti decision bolsters [its] legacy of protecting children’s health.”

“It’s important to appreciate what a monumental win this is. So many children have been rushed into injecting cross-sex hormones that are not meant for their developing bodies… Those who change course and accept their biological sex (known as ‘detransitioners’) all too often explain that the doctors who pushed them down this path did little to no looking into their underlying issues,” Campbell said. “To protect these children, Tennessee passed its law. With the Supreme Court’s ruling in Skrmetti, more children are likely to get the treatment they deserve instead of being rushed down a destructive road by adults who should know better.”

“There have been other signs that gender ideology is losing steam… A lawsuit in England brought by a young woman against the National Health System led to the closure of the Tavistock Gender Clinic, which then resulted in the study by Dr. Cass mentioned by Roberts in his opinion in Skrmetti,” Campbell wrote. “States have an interest in seeing that children are not subject to risky and unproven medical procedures. That’s why laws like Tennessee’s law is constitutional and why the Supreme Court upheld Tennessee’s effort to protect kids.”

In The Washington Post, Megan McArdle said “the ACLU bet big on a trans rights case. Its loss was predictable.”

“The plaintiffs were facing six conservative justices who needed to be convinced that such treatments are so compelling — as the litany goes, ‘lifesaving, evidence-based and medically necessary’ — that states could have no good reason to ban them,” McArdle wrote. “By the time the case reached the Supreme Court, that argument was hard to make, because more and more questions were raised about evidence supporting these treatments… We were left with semantic arguments about what constitutes discrimination on the basis of sex. The result was a major setback for the trans rights movement — not just a loss in this case, but a precedent that will make it harder to win elsewhere.”

“A long, open debate and an incremental approach to litigation had built broad cultural support for marriage equality. With trans rights, the pattern is the opposite: a series of rapid victories and an even more rapid decline in public support for issues such as gender-affirming care for minors and trans participation in sports,” McArdle said. “Backlash is a risk with any social change, of course. But it’s the ACLU’s job to understand that and plan for the contingency. In this case, the organization didn’t do that.”

In First Things, Theresa Farnan and Mary Rice Hasson called the ruling “a partial victory for common sense.”

The decision “dealt a significant blow to the transgender juggernaut, curtailing the strategy of using courts to thwart legislative or executive action that protects children from the harms of ‘transition’ procedures. But the Justices shied away from addressing more fundamental definitions of the human person, meaning we’ll likely see the transgender issue in court again before long,” Farnan and Hasson wrote. “The Court fails to tackle the underlying anthropological issue presented by ‘transgender’ claims, and it capitulates to gender ideology in its use of language. The majority opinion, for example, contrasts a ‘transgender boy (whose biological sex is female)’ with ‘a boy whose biological sex is male.’ Does a majority of the Court really believe that there are two kinds of ‘boys’ — those who are biologically male and those who are biologically female?”

“The majority opinion tiptoed around the 2020 Bostock decision, which prohibits workplace discrimination based on sexual orientation or ‘transgender status,’ declaring that it didn’t apply and need not be considered. Justices Alito and Thomas candidly declared that they believe Bostock to be wrongly decided. Until Bostock is overturned, individuals who identify as transgender will continue to demand that others validate their ‘transgender’ identity, and some lower courts will continue to twist language and law to comply with Bostock.”

What the left is saying.

• The left is critical of the decision, arguing that it rests on inconsistent logic.
• Some suggest that ambiguities in the ruling offer hope for the transgender community.
• Others say that the decision was driven by fear and prejudice.

In Slate, Mark Joseph Stern called Chief Justice Roberts’s opinion “a garbled mess.”

“The garbled result will undoubtedly set back the cause of LGBTQ+ equality and inflict grievous harm on transgender minors. But it also leaves lower courts room to continue defending trans rights, exploiting Roberts’ self-defeating sophistry to carve out protections where the majority fails to foreclose them,” Stern wrote. “Three justices — Clarence Thomas, Samuel Alito, and Amy Coney Barrett — wanted the court to issue a broad declaration that discrimination against transgender people is not inherently suspect under the Constitution’s equal protection clause… The chief justice was not (yet) willing to go that far. Neither, it seems, were Justices Brett Kavanaugh and Neil Gorsuch.”

“To hold together a six-justice majority in Skrmetti, then, Roberts presumably needed to argue that Tennessee’s law does not discriminate on the basis of sex or transgender status,” Stern said. “This approach, however, reduced his opinion to borderline gibberish. The problem is twofold. First, Tennessee did not hide the ball in targeting transgender children on the basis of sex; the Legislature expressly stated that its goal was to make minors ‘appreciate their sex’ by forcing them to live in accordance with it. Second, the law restricts access to specific medical care based on the sex assigned to a patient at birth. A cisgender boy seeking to enhance his male appearance is free to receive testosterone. A transgender boy seeking to enhance his male appearance cannot. Both seek gender-affirming care; only one can access it.”

In Erin in the Morning, Erin Reed said the ruling is “both devastating and limited.”

“The case raised foundational constitutional questions: whether transgender people constitute a class triggering higher constitutional scrutiny, whether laws targeting them violate equal protection, and whether the Constitution guarantees their right to access medically necessary treatment,” Reed wrote. “The Court sidestepped nearly all of those questions, instead issuing a narrower opinion that carves out an exception permitting medical discrimination based on ‘gender dysphoria’ — a distinction it bizarrely treats as separate from discrimination against transgender people. The ruling effectively greenlights medical care bans across the country and may pave the way for broader restrictions, including for adults.”

“Several rulings in recent months will remain unaffected by the Court’s decision. Just yesterday, a federal judge certified a class of transgender people in a lawsuit challenging a passport ban and opened the door for gender marker updates… As a result, the impact of this ruling is likely to remain confined to the medical context — for now. Still, the decision provides a blueprint for future legislation targeting ‘gender dysphoria’ as a proxy for discriminating against transgender people without explicitly naming transgender status or sex,” Reed said. “And yet, the ruling leaves cracks in the foundation — enough space, for now, to regroup and keep fighting.”

In The New York Times, M. Gessen criticized “the Supreme Court’s blindness to transgender reality.”

“Having rejected the argument for heightened scrutiny in the Tennessee case, the court applied what’s called the rational basis approach, which the court itself has described as ‘a relatively relaxed standard.’ Under this standard, Tennessee didn’t have to prove that its interest in restricting trans care served a purpose that would override concerns about discrimination,” Gessen wrote. “The majority chose to take at face value the rationale the Tennessee legislature had used for its law. This rationale consists of more and less widespread cultural myths and a few outright fabrications.”

“The Tennessee law and now the Supreme Court decision that upheld it are part of a vast backlash against trans rights, a backlash that includes President Trump’s executive orders purging trans service members, banning ‘gender ideology’ and decreeing the existence of two immutable sexes. This backlash is part of a larger cultural retrenchment that reaches far beyond the conservative Supreme Court or the borders of the MAGA universe,” Gessen said. “This retrenchment is fueled by fear: fear of the future, fear of unfamiliar concepts, fear of not knowing one’s child… Many an anxious American parent wants the option itself to disappear. How convenient it would be if trans people could be executive-ordered and legislated away.”

My take.

Reminder: “My take” is a section where I give myself space to share my own personal opinion. If you have feedback, criticism or compliments, don't unsubscribe. Write in by replying to this email, or leave a comment.

• Legally, I think the court should have assessed the law under stricter scrutiny.
• Practically, I worry about the nationwide effects this ruling will have.
• I don’t underestimate the risks of these treatments, but I think the government doesn’t help by instituting strict, overly broad bans.

Today, I’m going to use my two-bucket framework for discussing Supreme Court cases: first, an analysis of the legal arguments, then a look at the practical outcomes of the ruling.

As I wrote last year, the Supreme Court should have sent this case back to the lower courts with a heightened scrutiny standard applied. I’m not contesting that Tennessee has an interest and the constitutional right to pass laws intended to protect minors from perceived risk, nor do I think a lower court would have necessarily struck this law down under a stricter standard. I’m simply convinced, after listening to oral arguments in the case (and reading Justice Sotomayor’s dissent), that a sex-based discrimination question is at the heart of Tennessee’s law, meaning the case should have been argued under intermediate scrutiny. Here’s what I wrote in December:

Justice Jackson’s exchange with Matthew Rice, the Tennessee solicitor general, made it clear that this law invites real questions about sex-based discrimination. Jackson posed the hypothetical of a boy wanting to take testosterone to deepen his voice and enhance his masculinity. Rice eventually conceded that, yes, the law would allow this — and then admitted that a girl who wanted to take testosterone to deepen her voice would not be allowed to do the same. Jackson argues that the difference here is the sex of the patient, while Rice argued that the difference was the purpose of the medication. But Jackson rightly pointed out that other statutes limit the use of these drugs based on purpose, not the law in question; thus, this law’s limiting factor seems to only be sex (the entire exchange is genuinely worth reading). Therefore, the state has to defend the law under heightened scrutiny.

Although strong counterarguments opposing Jackson’s are worth considering, the logic employed by the majority hasn’t changed my mind about stricter scrutiny. To the contrary, it is apparent early in Chief Justice Roberts’s decision that he is trying to wrangle the disparate views of the six Republican-appointed justices, which created a major mess. As Mark Joseph Stern explained, “Three justices — Clarence Thomas, Samuel Alito, and Amy Coney Barrett — wanted the court to issue a broad declaration that discrimination against transgender people is not inherently suspect under the Constitution’s equal protection clause.” 

Roberts didn’t want to go that far, and neither did Kavanaugh or Gorsuch (who have previously affirmed or expressed support for protections for trans people in some of these settings). So Roberts tried to cobble together a position that held that Tennessee’s law did not discriminate against trans people or on the basis of sex, even though it was very obviously inextricable with sex (the bill literary states it is “encouraging minors to appreciate their sex,” and it prohibits trans boys from taking medicine that other boys can take). 

I certainly understand the messy work of being a chief justice, but Roberts stitched together a Frankenstein ruling that will introduce a great deal of uncertainty, creating openings for future defenses of trans rights as well as challenges to unrelated anti-discrimination laws. Oddly, I would have been more convinced if the majority had accepted that plain-language discrimination against transgender people existed in the bill, but found that transgender people did not qualify as an immutable class with distinguishing characteristics. A ruling like that — at the intersection of Alito’s view that the Tennessee law classifies treatments on transgender status and Barrett’s view that transgender people don’t meet the definition of a “suspect class” — would have been a more consistent, logical, and straightforward opinion (though worse for the trans-rights movement). 

That brings me to the practical outcomes, which will be immediately felt across the country. Roughly two dozen states have laws similar to Tennessee’s that lower courts are now much likelier to rubber stamp, meaning any treatments tied to medication or surgery in those states are going to be widely prohibited. Roughly 3% of American high schoolers now identify as transgender, and only a small fraction of them seek medical treatment for gender dysphoria, but it's safe to assume thousands of kids could be impacted by treatment bans. 

This outcome could easily be read as a story about trans-rights activists getting out over their skis. After successfully fighting off bathroom bills, winning a workplace discrimination case before the Supreme Court and (temporarily) reversing the ban on trans individuals openly serving in the military, the next logical step was to protect healthcare for transgender people. But many LGBTQ advocacy groups were deeply skeptical about bringing a case on gender treatment for minors to the Supreme Court, and those concerns were well founded. This loss represents a pivotal failure for the trans-rights movement, and — paired with Trump’s election and immediate rollback of Biden-era rules — the turnaround has been unbelievably fast. 

I think this ruling tells a simple story about where the country is on these issues: Broadly speaking, Americans have shown an openness to trans rights — and polling shows that protecting trans people from hate crimes, banning workplace discrimination against trans people, allowing them to serve in the military, and even requiring gender-neutral bathrooms in public places are all popular proposals. Conversely, most Americans’ sensibilities seem to be offended on issues like trans participation in sports, children attending drag shows, public school lessons on trans issues, and whether transgender people use bathrooms that do not correspond to their biological sex. This picture is one of a country that is broadly interested in protecting trans rights, but also fearful of the way kids might be impacted by the trans-rights movement or by treating their gender dysphoria with medication and surgery that has lasting implications.  

Still, something about this ruling just feels wrong to me — and not because I think treating kids who report gender dysphoria with hormones or surgery is always right. A growing body of evidence suggests that the positive outcomes of these treatments is unclear but the risks are significant: Hormone therapies can increase cardiac health events and fertility issues, on top of causing permanent changes to the body that may not be desired; puberty blockers can interfere with bone health and have unknown long-term impacts; and gender-transition surgeries can cause infertility, excessive bleeding, or chronic pain. Regret rates for these surgeries are quite low, but they’re far from nonexistent — underscoring the value of waiting until adulthood to make such a consequential decision. 

However, every medical treatment carries risk. We give kids prescription drugs for depression, anxiety, ADHD, and sleep issues that could cause major long-term adverse effects. Perhaps more relevantly, no federal laws ban plastic surgery for minors with parental consent — which carry similar risks of complications or regret later on in life. Most of us intuitively understand that medical treatments always carry trade-offs or that minors can get surgeries that carry risks with the consent and support of parents, but we very rarely legally prohibit these treatments or surgeries. Why is care for transgender minors different? 

Given how popular banning youth from accessing puberty blockers and hormones is, I think it is reasonable for Tennessee legislators to try to act on the will of their constituents. I also recognize this is probably one of my most unpopular views I’ve ever expressed in this newsletter. But my view is generally in line with my broader ideology: I don’t like it when the government limits individual choice. If doctors and parents think hormone therapy or puberty blockers are the best treatment for their children, then it doesn’t feel right to me that a group of legislators can take away that choice. Even if these policies are popular, they strike me as a plain infringement on the rights of families — and a reasonable place for courts to step in.

Yes, these treatments have probably been too liberally applied, carry significant risks, and must involve the parents; but it’s not the government’s job to tell parents what is best for their kids on an issue that directly affects their livelihood, or tell doctors what is best for their patients. The government rightly regulates some activities for minors — like access to alcohol or tobacco, or ensuring kids go to school — but the risk-benefit profiles in those examples are far more obvious and clear to me than they are here. For all these reasons, I worry about the practical implications of this ruling — and will be closely following the real-world implications for families across the country. 

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Your questions, answered.

Q: Did Trump *have to* seek Congress' approval for the strike on Iran?

— Ezra from Mountain Lakes, NJ

Tangle: On one hand, Article I of the Constitution does clearly say that only Congress can declare war. However, as usual, it’s a little more complicated than that. President Trump can claim that the recent U.S. strikes in Iran were constitutional in two ways.

First, he can claim it was a limited strike that falls under his authority as commander in chief of the armed forces, as defined by Article II of the Constitution. This is the argument that President Obama famously advanced when authorizing drone strikes in Libya in 2011. The argument is controversial, but it also covers other strikes from modern presidents that have been popularly accepted: Reagan in Libya in 1986, Clinton in Sudan and Afghanistan in 1998, and Trump in Syria in 2017 and 2018.

Second, under the War Powers Resolution of 1973, Trump could report to Congress if “introducing United States Armed Forces into hostilities or into situations where imminent involvement in hostilities is clearly indicated by the circumstances.” However, he must do so within 48 hours, and the authorization only lasts for 60 days (plus another 30 for troop withdrawal). 

Reps. Thomas Massie (R-KY) and Ro Khanna (D-CA) recently invoked this 1973 legislation, sponsoring a resolution in the House that says Trump must report to Congress for any entanglements in Iran. However, Trump could say that the initial strike was limited in scope and falls under Article II, then notify Congress of any further military actions. And if the situation escalates to the point where Trump wants to engage the armed forces in a more sustained way, he still has one more option before asking for a declaration of war: seeking an authorization of the use of military force (AUMF) to take defined and limited military acts. President George H.W. Bush used an AUMF for the Gulf War in 1991, and President George W. Bush used one to mobilize troops in Afghanistan in 2001.

The strikes on Saturday night seem similar to other actions that were covered by Article II, so — pending any Congressional demands — Trump seems to be in the clear. Although if the U.S. commitment in Iran escalates, President Trump will likely have to involve Congress.

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Under the radar.

As the Senate considers the “big, beautiful bill” passed by the House, Senate Parliamentarian Elizabeth MacDonough has advised that a slew of measures cannot be included in the bill if Republicans want to pass it via budget reconciliation, which requires a simple majority vote. However, reconciliation also demands that a bill’s provisions be primarily related to the budget. According to Democrats, MacDonough said that measures barring people living in the country illegally from receiving nutrition assistance, requiring the U.S. Postal Service to sell its electric vehicles, and reducing the Consumer Financial Protection Bureau’s funding to zero (among several others) did not qualify. Senate Republicans now must decide whether to attempt to overrule MacDonough, which they’ve previously indicated they won’t do, or strip the provisions from the bill to proceed with reconciliation. The Wall Street Journal has the story.

Numbers.

• 27. The number of states that have enacted laws banning gender-affirming care for minors as of June 2025.
• 2. Of those states, the number whose laws are currently blocked by court orders. 
• 84. The number of amicus briefs filed in United States v. Skrmetti.
• 32. The number of amicus briefs filed in support of the petitioners.
• 51. The number of amicus briefs filed in support of the respondents.
• +10%. The increase in the percentage of U.S. adults who favor banning health care professionals from providing care related to gender transitions for minors between 2022 and 2025, according to Pew Research.
• +7%. The increase in the percentage of Republicans who favor banning health care professionals from providing care related to gender transitions for minors between 2022 and 2025.
• +9%. The increase in the percentage of Democrats who favor banning health care professionals from providing care related to gender transitions for minors between 2022 and 2025.

The extras.

• One year ago today we wrote about the Supreme Court’s gun-control ruling.
• The most clicked link in yesterday’s newsletter was the shooting at a church in suburban Detroit.
• Nothing to do with politics: Exploring the craze for the subjectively off-putting Labubu dolls.
• Yesterday’s survey: 3,188 readers responded to our survey on the U.S. bombing Iran with 41% saying our military commitment in the country will be at least a year. “It could well get much worse if Iran hits a US base and causes many casualties,” one respondent said.

Have a nice day.

Don Tomas has been selling ice cream to his Florida community members to help them cope with the summer heat for years. When a TikToker noticed Don pushing his heavy ice cream cart next to a highway, she was moved enough to post a video of herself handing out some extra money to him — then moved again to see how many people commented on the video who recognized him. The response prompted her to set up a GoFundMe, which has raised over $30,000 for an ice cream truck. Soon, Don will be able to sell the heat-relieving treat while getting that same relief for himself. Sunny Skyz has the story.

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