## Facts

- Tennessee and Kentucky enacted statutes restricting specified medical treatments for minors when used to enable a minor to identify with a gender different from the minor’s sex at birth.
- The restrictions covered, as relevant on appeal, the prescription or administration of puberty blockers and cross-sex hormones for minors diagnosed with gender dysphoria, while allowing certain exceptions (e.g., congenital defects, precocious puberty, disease, or injury) and limited continuation of some existing courses of treatment.
- The Tennessee law imposed potential professional discipline and provided a private right of action against medical providers for violations.
- Transgender minors, their parents, and a physician challenged the laws, alleging violations of (a) substantive due process based on parental rights to direct a child’s medical care and (b) equal protection based on sex and transgender-status discrimination.
- Federal district courts in Tennessee and Kentucky granted preliminary injunctions blocking enforcement of the challenged restrictions (at least as to puberty blockers and hormones); Tennessee and Kentucky appealed, and the appeals were consolidated.

## Issues

1. Whether the challenged restrictions likely violate substantive due process by infringing a fundamental parental right to obtain puberty blockers and cross-sex hormones for minors.
2. Whether the restrictions likely violate equal protection by discriminating based on sex or transgender status, and what level of scrutiny applies.
3. Whether the district courts erred by granting broad facial preliminary injunctions rather than narrower relief.

## Decision

- The Sixth Circuit reversed the preliminary injunctions and permitted Tennessee and Kentucky to enforce the challenged restrictions pending further proceedings.
- The court held the plaintiffs had not shown a likelihood of success on a substantive due process theory because the asserted right was not a fundamental right under the court’s historical-tradition analysis.
- The court applied rational basis review and concluded the States had rational reasons to regulate the treatments for minors in light of asserted risks and disputed medical questions.
- The court rejected the argument that the statutes amounted to unconstitutional sex discrimination and declined to treat transgender status as a quasi-suspect classification warranting heightened scrutiny.
- The court faulted the breadth of the injunctions, reasoning that facial invalidation is disfavored and was not justified on the preliminary record.

## Legal Principles

- Fundamental-right substantive due process claims require a carefully defined asserted liberty interest and must be supported by a showing that the right is deeply rooted in the Nation’s history and traditions.
- Parental decision-making interests in a child’s care do not necessarily include a constitutional entitlement to demand specific, contested medical interventions for minors free from state regulation.
- When no fundamental right or suspect/quasi-suspect classification is established, legislation regulating medical practice is generally evaluated under rational basis review and will be upheld if supported by any rational governmental interest.
- Equal protection scrutiny turns on whether a law classifies on an impermissible basis; regulation of procedures applicable to all minors, as framed by the court, does not automatically constitute sex-based classification.
- Facial preliminary injunctions are disfavored; broad relief requires a strong showing that the law lacks valid applications and that sweeping equitable relief is warranted on the preliminary record.

## Conclusion

The Sixth Circuit reversed preliminary injunctions against Tennessee’s and Kentucky’s restrictions on puberty blockers and cross-sex hormones for minors, holding that the plaintiffs were unlikely to succeed on substantive due process or equal protection claims because the statutes were subject to, and satisfied, rational basis review and did not trigger heightened scrutiny.


L.W. ex rel. Williams v. Skrmetti, 83 F.4th 460 (6th Cir. 2023)