Ignoring the Evidence: The Skrmetti Decision

By Ella Lesher

The verdict is in. Science can speak, but the law isn’t always listening.

On Wednesday, June 18, the U.S. Supreme Court issued a 6-3 decision in United States v. Skrmetti, upholding Tennessee’s Senate Bill 1 (SB1). SB1 bars doctors from providing gender-affirming care, including puberty blockers, hormones, and surgical procedures, for transgender minors. Chief Justice Roberts penned the Court’s opinion, with Justices Thomas, Gorsuch, Kavanaugh, Barrett, and Alito signing on. Although legally narrow, their decision endangers transgender youth nationwide by giving states a green light to enact and enforce similar laws, leaving access to care dependent on where someone lives.

This landmark case represents more than a legal precedent—it marks a critical juncture in the relationship between scientific evidence and judicial decision-making, raising fundamental questions about how medical consensus influences legal interpretation and the role of empirical research in constitutional analysis.

The Legal Framework

At the heart of the Skrmetti decision is the Equal Protection Clause of the Fourteenth Amendment, which tells us that no state shall “deny to any person within its jurisdiction the equal protection of the laws.” Typically, laws that discriminate based on sex are subject to “intermediate scrutiny,” meaning courts must determine whether the legislation serves an important government interest and is substantially related to that objective.

However, Tennessee successfully argued that SB1 does not discriminate based on sex or transgender status. Instead, the state claimed the law simply sets age- and use-based limits on certain medical procedures. SB1 prohibits healthcare providers from performing medical procedures on minors if those procedures are intended to “enabl[e] a minor to identify with, or live as, a purported identity inconsistent with the minor’s sex” or treat “purported discomfort or distress from a discordance between the minor’s sex and asserted identity.” The statute defines “sex” as “a person’s immutable characteristics of the reproductive system that define the individual as male or female, as determined by anatomy and genetics existing at the time of birth.” Despite this language linking the ban to sex assigned at birth, the Supreme Court insisted that SB1 does not discriminate based on sex.

This framing was crucial because it allowed the Court to apply “rational basis review” rather than the heightened “intermediate scrutiny.” Rational basis review is a highly deferential standard, requiring only that a law be rationally related to a legitimate government interest, such as public health. Legislation subject to this standard needs a plausible justification, not scientific proof. This is a very low bar, giving significant leeway to legislative judgments. As the majority stressed, the role of the Supreme Court is not “to judge the wisdom, fairness, or logic” of legislation, but to ensure it does not violate the U.S. Constitution. Applying this lenient standard to laws restricting medical treatments raises serious concerns about how scientific expertise and judicial authority intertwine, effectively prioritizing legislative policy decisions over clinical evidence.

The Scientific Landscape

A significant point of contention within the judicial system is its apparent disregard for established scientific consensus. Let’s be clear: the medical community has largely converged on robust, evidence-based support for gender-affirming care. Though Justice Thomas deems them irrelevant in his concurrence, major medical associations, including the American Medical Association, American Academy of Pediatrics, and American Psychological Association, have endorsed these treatments as safe and medically necessary for treating gender dysphoria. They later issued joint statements expressing disappointment with the decision, emphasizing their commitment to evidence-based care. Furthermore, the American Academy of Child and Adolescent Psychiatry recommends that “all children and adolescents have access to multi-disciplinary, evidence-based, and trauma-informed gender-affirming health care.” The research underlying these positions indicates that gender-affirming care can substantially improve mental health outcomes and reduce suicide risk among transgender youth.

The majority, however, defers rather uncritically—under rational basis review—to Tennessee’s assertions about the risks of gender-affirming care while dismissing or minimizing the overwhelming evidence of its benefits. For example, the Court makes much of the fact that some individuals express regret after receiving gender-affirming care. This is true; the prevalence of regret after gender-affirming surgery is about 1%. Yet, the prevalence of regret across all surgical procedures is about 14%, and there is no medical procedure with a 0% regret rate.

The Evidence-Law Interface

The Skrmetti case zeroes in on how scientific evidence gets treated (or mistreated) within the legal field. Justice Thomas went so far as to dismiss the role of science in the judicial system, writing, “the views of self-proclaimed experts do not shed light on the meaning of the Constitution.” He deems the expertise of major medical organizations “irrelevant” and the work of researchers “elite sentiment.” It is worth noting that none of the current Supreme Court justices have a background in science or medicine.

SB1’s regulatory structure further highlights this disconnect. SB1 permits certain medical interventions when used for specific purposes while prohibiting identical treatments when used for gender-affirming care. For instance, the law allows puberty blockers for treating precocious puberty but prohibits their use for gender dysphoria.

This distinction raises important questions about how legal systems evaluate medical evidence. We’re talking about the exact same medication, with the exact same pharmacological properties and similar risk profiles, getting different legal treatment based purely on its intended therapeutic use. From a scientific vantage point, this creates an unusual precedent where the legal permissibility of an evidence-based medical intervention isn’t about its safety or efficacy but the name of the condition it’s aiming to treat.

The Challenge of Translating Science to Law

Skrmetti emphasizes the persistent challenge of effectively communicating complex, evolving medical science within legal frameworks that crave binary determinations. Medical evidence rarely provides absolute certainty; instead, it offers probabilistic assessments of risk and benefit that must be weighed against individual patient circumstances.

The legal system, however, often requires more definitive determinations. Courts must decide whether evidence is sufficient to support or reject particular legal conclusions, creating tension when scientific understanding is nuanced or evolving. For example, the decision in Daubert v. Merrell Dow Pharmaceuticals, Inc. requires judges to act as gatekeepers of scientific expert testimony, assessing its reliability and relevance before it can be presented in court. To learn more, read about the Daubert standard on our blog here! As seen in Skrmetti, areas of uncertainty or ongoing research can be used to justify restrictive legislation, even when the vast weight of evidence supports the restricted practice.

In this case, the Court acknowledged the “fierce scientific and policy debates about the safety, efficacy, and propriety of medical treatments in […] evolving field[s]” like pediatric gender-affirming care. Rather than relying on expert witnesses who contradict mainstream medical science, Tennessee’s lawyers underscored areas of tension and the evolving nature of the research. Ultimately, the Court left questions regarding the scientific and societal implications of SB1 “to the people, their elected representatives, and the democratic process.”

The Verdict

While professional medical organizations carry significant scientific authority, their positions do not automatically translate into legal protection for the treatments they endorse. By upholding legislation that restricts medical treatments despite supporting scientific evidence, the Court established a precedent that legislative bodies can override professional medical judgment in certain contexts.

This disconnect between medical consensus and legal protection raises critical questions about the role of scientific expertise in democratic governance. Should courts defer to medical professionals’ clinical judgment when evaluating the constitutionality of laws restricting medical practice? Or should elected legislatures have primary authority to make policy determinations about medical treatments, even when those determinations fly in the face of prevailing medical opinion?

For scientists and medical professionals, the Skrmetti case serves as a reminder that empirical evidence, while crucial, operates within broader legal and political contexts that shape how that evidence influences policy and practice. Understanding these dynamics is essential for effectively translating scientific findings into meaningful improvements in public health and medical care.

The verdict is in. Science can speak, but the law isn’t always listening.