## Facts

- Tennessee enacted 2023 Public Chapter No. 1 (SB1), limiting certain medical interventions for minors.
- SB1 bars health-care providers from prescribing, administering, or dispensing puberty blockers or cross-sex hormones to minors when used to help a minor live as an identity inconsistent with the minor’s sex, or to treat distress arising from such discordance (often described as gender dysphoria, gender identity disorder, or gender incongruence).
- SB1 allows the same medications for minors for other specified medical purposes (such as certain congenital conditions, precocious puberty, disease, or injury).
- Transgender minors, their parents, and a physician sued Tennessee officials, asserting SB1 violates the Equal Protection Clause and substantive due process (including parental decision-making about medical care).
- In a separate case, plaintiffs challenged a Kentucky law restricting similar treatments; a preliminary injunction issued there as well. The Sixth Circuit consolidated the Tennessee and Kentucky appeals for argument and decision.
- The district court in Tennessee preliminarily enjoined enforcement of key parts of SB1 (as to puberty blockers and hormones), finding plaintiffs likely to succeed on the merits and to suffer irreparable harm absent relief.
- Tennessee officials appealed. The United States intervened in support of the challengers.

## Issues

1. Whether the Tennessee preliminary injunction should stand under the abuse-of-discretion standard governing appellate review of preliminary injunctions.
2. Whether SB1 likely violates the Equal Protection Clause by drawing a sex-based classification or a classification based on transgender status, thereby requiring heightened scrutiny.
3. If heightened scrutiny does not apply, whether SB1 is likely valid under rational-basis review.
4. Whether SB1 likely violates substantive due process by infringing a fundamental right of parents to obtain puberty blockers or cross-sex hormones for their minor children.
5. Whether standing—especially redressability—required additional attention on remand in evaluating entitlement to preliminary relief.

## Decision

- The Sixth Circuit (Chief Judge Sutton, joined by Judge Thapar; Judge White dissenting in part) reversed the Tennessee district court’s preliminary injunction to the extent it blocked SB1’s restrictions on puberty blockers and cross-sex hormones for minors.
- The court held the plaintiffs had not shown a sufficient likelihood of success on the merits of their Equal Protection claim because SB1, as framed, is an age- and medical-use-based regulation rather than a sex-based classification, and the court declined to treat transgender status as a suspect or quasi-suspect class at this stage.
- Applying rational-basis review, the court concluded Tennessee’s asserted reasons—protecting minors and regulating medical practice amid uncertainty about risks and long-term effects—were enough to defeat a preliminary finding of likely unconstitutionality.
- The court also held plaintiffs had not shown a likelihood of success on their substantive due process claim: existing parental-rights precedents do not establish a fundamental right to access these particular medical treatments in the face of state regulation.
- The court remanded with instructions that the district court consider additional justiciability concerns, including standing and redressability, as part of the likelihood-of-success analysis.
- In the consolidated Kentucky appeal, the court’s disposition aligned with its Tennessee reasoning at the preliminary-injunction stage, resulting in relief from the injunction to the extent inconsistent with the Sixth Circuit’s analysis.

## Legal Principles

- Appellate review of a preliminary injunction is for abuse of discretion, but a district court necessarily abuses its discretion if it makes an error of law in assessing likelihood of success on the merits.
- For Equal Protection analysis, the first step is identifying the classifications the statute draws on its face; a law restricting medical treatments for minors based on age and specified medical indications is not automatically treated as sex discrimination.
- Absent a recognized suspect or quasi-suspect classification, and absent a fundamental right, rational-basis review applies; under that standard, a state may regulate medical practice for minors based on risk, uncertainty, and legislative line-drawing.
- Disagreement in medical and scientific debates does not by itself justify preliminary invalidation of a statute under rational-basis review; the question is whether the legislature could have had a rational reason for the rule.
- Substantive due process analysis is cautious about expanding fundamental-rights doctrine to new claimed rights; parental-rights cases recognizing authority over upbringing and education do not necessarily create a constitutional right to obtain any particular medical intervention for a child.
- Article III standing, including redressability, bears on entitlement to preliminary relief; courts may require further development of standing at the injunction stage because it affects the merits-related likelihood-of-success inquiry.

## Conclusion

In *L.W. v. Skrmetti*, the Sixth Circuit reversed key portions of preliminary injunctions that had blocked Tennessee’s SB1 (and related Kentucky restrictions) on puberty blockers and cross-sex hormones for minors, holding that challengers had not shown a likelihood of success on Equal Protection or substantive due process theories, that rational-basis review applied and was satisfied, and that further consideration of standing—especially redressability—was warranted on remand.


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