Tennessee Ban on Sexual-Identity-Related Medical Procedures for Minors Is Likely Constitutional,

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[UPDATE: I hadn’t realized that Jonathan Adler had posted about this before me; see his post and its comments here.]

From L.W. v. Skrmetti, decided today by the Sixth Circuit, in an opinion by Judge Jeffrey Sutton joined by Judge Amul Thapar:

Tennessee enacted a law that prohibits healthcare providers from performing gender-affirming surgeries and administering hormones or puberty blockers to transgender minors. After determining that the law likely violated the Equal Protection and Due Process Clauses, the district court facially enjoined the law’s enforcement as to hormones and puberty blockers and applied the injunction to all people in the State. Tennessee appealed and moved for an emergency stay of the district court’s order. Because Tennessee is likely to succeed on its appeal of the preliminary injunction, we grant the stay….

In March 2023, Tennessee enacted the Prohibition on Medical Procedures Performed on Minors Related to Sexual Identity…. Seeking to “protect[] minors from physical and emotional harm,” the legislature identified several concerns about recent treatments being offered by the medical profession for children with gender dysphoria. It was concerned that some treatments for gender dysphoria “can lead to the minor becoming irreversibly sterile, having increased risk of disease and illness, or suffering adverse and sometimes fatal psychological consequences.” It was concerned that the long-term costs of these treatments remain unknown and outweigh any near-term benefits because they are “experimental in nature and not supported by high-quality, long-term medical studies.” And it noted that other helpful, less risky, and non-irreversible treatments remain available.

These findings convinced the legislature to ban certain medical treatments for minors with gender dysphoria. A healthcare provider may not “administer or offer to administer” “a medical procedure” to a minor “for the purpose of” either “[e]nabling a minor to identify with, or live as, a purported identity inconsistent with the minor’s sex,” or “[t]reating purported discomfort or distress from a discordance between the minor’s sex and asserted identity.”  Prohibited medical procedures include “[s]urgically removing, modifying, altering, or entering into tissues, cavities, or organs” and “[p]rescribing, administering, or dispensing any puberty blocker or hormone.”

The Act contains two relevant exceptions. It permits the use of these medical procedures to treat congenital defects, precocious puberty, disease, or physical injury. And it has a “continuing care” exception until March 31, 2024, which permits healthcare providers to continue administering a long-term treatment, say hormone therapy, that began before the Act’s effective date.

The district court blocked enforcement of the law, but the Court of Appeals stayed the decision pending appeal, concluding that the challengers were unlikely to prevail on their parental rights (substantive due process) and equal protection claims:

First, the challengers do not argue that the original fixed meaning of either the due process or equal protection guarantee covers these claims. That prompts the question whether the people of this country ever agreed to remove debates of this sort—about the use of new drug treatments on minors—from the conventional place for dealing with new norms, new drugs, and new technologies: the democratic process. Life-tenured federal judges should be wary of removing a vexing and novel topic of medical debate from the ebbs and flows of democracy by construing a largely unamendable federal constitution to occupy the field.

Second, while the challengers do invoke constitutional precedents of the Supreme Court and our Court in bringing this lawsuit, not one of them resolves these claims. In each instance, they seek to extend the constitutional guarantees to new territory. There is nothing wrong with that, to be sure. But it does suggest that the key premise of a preliminary injunction—likelihood of success on the merits—is missing. The burden of establishing an imperative for constitutionalizing new areas of American life is not—and should not be—a light one, particularly when “the States are currently engaged in serious, thoughtful” debates about the issue.

Third, the States are indeed engaged on these issues, as the recent proliferation of legislative activity across the country shows. Compare Ga. Code Ann. § 31-7-35 (banning gender-affirming treatments for minors) and Idaho Code § 18-1506C (similar), with Cal. Penal Code § 819 (prohibiting cooperation with other states as to gender-affirming care provided to out-of-state minors in California), Colo. Rev. Stat. § 12-30-121(1)(d) (designating gender- affirming care as “legally protected health-care activity”), and Minn. Stat. § 260.925 (refusing to enforce out-of-state laws that would limit a parent’s custody rights for consenting to gender- affirming care). See also Ala. Code § 16-1-52 (restricting sports participation by transgender students); Wyo. Stat. Ann. § 21-25-102 (similar); Mont. Code Ann. § 40-6-7X1(1)(f) (requiring parental consent for changes in a child’s pronouns). Leaving the preliminary injunction in place starts to grind these all-over-the-map gears to a halt. Given the high stakes of these nascent policy deliberations—the long-term health of children facing gender dysphoria—sound government usually benefits from more rather than less debate, more rather than less input, more rather than less consideration of fair-minded policy approaches. To permit legislatures on one side of the debate to have their say while silencing legislatures on the other side of the debate under the U.S. Constitution does not further these goals.

That many members of the medical community support the plaintiffs is surely relevant. But it is not dispositive for the same reason we would not defer to a consensus among economists about the proper incentives for interpreting the impairment-of-contracts or takings clauses of the U.S. Constitution. At all events, the medical and regulatory authorities are not of one mind about using hormone therapy to treat gender dysphoria. Else, the FDA would by now have approved the use of these drugs for these purposes. That has not happened, however, giving us considerable pause about constitutionalizing an answer they have not given or, best we can tell, even finally studied.

Due process. The challengers argue that the Act violates their due process right to control the medical care of their children…. Parents, it is true, have a substantive due process right “to make decisions concerning the care, custody, and control of their children.” But the Supreme Court cases recognizing this right confine it to narrow fields, such as education, and visitation rights. No Supreme Court case extends it to a general right to receive new medical or experimental drug treatments. In view of the high stakes of constitutionalizing areas of public policy, any such right must be defined with care. The challengers have not shown that a right to new medical treatments is “deeply rooted in our history and traditions” and thus beyond the democratic process to regulate.

Constitutionalizing new parental rights in the context of new medical treatments is no mean task. On the one side of the ledger, parents generally can be expected to know what is best for their children. On the other side of the ledger, state governments have an abiding interest in “preserving the welfare of children,” and “in protecting the integrity and ethics of the medical profession.” These interests give States broad power, even broad power to “limit[] parental freedom,” particularly in an area of new medical treatment. We doubt, for example, that there are many drug-regulatory agencies in the world that, without satisfactory long-term testing, would delegate to parents and a doctor exclusive authority to decide whether to permit a potentially irreversible new drug treatment.

More generally, state legislatures play a critical role in regulating health and welfare, and their efforts are usually “entitled to a ‘strong presumption of validity.'” As a result, federal courts must be vigilant not to “substitute” their views for those of legislatures, a caution that is particularly apt when construing unenumerated guarantees.

Judicial deference is especially appropriate where “medical and scientific uncertainty” exists…. Gender-affirming procedures often employ FDA-approved drugs for non-approved, “off label” uses. Tennessee decided that such off-label use in this area presents unacceptable dangers. Many medical professionals and many medical organizations may disagree. But the Constitution does not require Tennessee to view these treatments the same way as the majority of experts or to allow drugs for all uses simply because the FDA has approved them for some. It is well within a State’s police power to ban off-label uses of certain drugs. At the same time, it is difficult to maintain that the medical community is of one mind about the use of hormone therapy for gender dysphoria when the FDA is not prepared to put its credibility and careful testing protocols behind the use….

Equal protection…. Statutory classifications are ordinarily valid if they are rationally related to and further a legitimate state interest. More exacting scrutiny applies when a law implicates protected classes.

It’s highly unlikely, as an initial matter, that the plaintiffs could show that the Act lacks a rational basis. The State plainly has authority, in truth a responsibility, to look after the health and safety of its children. In this area of unfolding medical and policy debate, a State has more rather than fewer options. Tennessee could rationally take the side of caution before permitting irreversible medical treatments of its children.

The challengers pin their main claims for likelihood of success on the assumption that heightened scrutiny applies. They first argue that the Tennessee Act discriminates on the basis of sex and thus requires the State to satisfy intermediate scrutiny. We are skeptical.

The Act bans gender-affirming care for minors of both sexes. The ban thus applies to all minors, regardless of their biological birth with male or female sex organs. That prohibition does not prefer one sex to the detriment of the other. The Act mentions the word “sex,” true. But how could it not? That is the point of the existing hormone treatments—to help a minor transition from one gender to another. That also explains why it bans procedures that administer cross-sex hormones but not those that administer naturally occurring hormones. A cisgender girl cannot transition through use of estrogen; only testosterone will do that. A cisgender boy cannot transition through use of testosterone; only estrogen will do that. The reality that the drugs’ effects correspond to sex in these understandable ways and that Tennessee regulates them does not require skeptical scrutiny. “The regulation of a medical procedure that only one sex can undergo does not trigger heightened constitutional scrutiny unless the regulation is a ‘mere pretex[t] designed to effect an invidious discrimination against the members of one sex or the other.'” No such pretext has been shown here. If a law restricting a medical procedure that applies only to women does not trigger heightened scrutiny, as in Dobbs, a law equally appliable to all minors, no matter their sex at birth, does not require such scrutiny either.

The plaintiffs separately claim that the Act amounts to transgender-based discrimination, violating the rights of a quasi-suspect class. But neither the Supreme Court nor this court has recognized transgender status as a quasi-suspect class. Until that changes, rational basis review applies to transgender-based classifications. In the context of a preliminary injunction and the need to establish a likelihood of success on the merits, that should be nearly dispositive given the requirement of showing a “clear” right to relief.

The bar for recognizing a new quasi-suspect class, moreover, is a high one. The Supreme Court has recognized just two such classes … (gender and illegitimacy), and none in recent years. The Court “has not recognized any new constitutionally protected classes in over four decades, and instead has repeatedly declined to do so.”

That hesitancy makes sense here. Gender identity and gender dysphoria pose vexing line-drawing dilemmas for legislatures. Plenty of challenges spring to mind. Surgical changes versus hormone treatment. Drugs versus counseling. One drug versus another. One age cutoff for minors versus another. Still more complex, what about sports, access to bathrooms, definitions of disability? And will we constitutionalize the FDA approval rules in the process? Even when accompanied by judicial tiers of scrutiny, the U.S. Constitution does not offer a principled way to judge each of these lines—and still others to boot. All that would happen is that we would remove these trying policy choices from fifty state legislatures to one Supreme Court. Instead of the vigorous, sometimes frustrating, “arena of public debate and legislative action” across the country and instead of other options provided by fifty governors and fifty state courts, we would look to one judiciary to sort it all out. That is not how a constitutional democracy is supposed to work—or at least works best—when confronting evolving social norms and innovative medical options.

Bostock v. Clayton County (2020) does not change the analysis. Title VII’s prohibition on employment discrimination “because of … sex” encompasses discrimination against persons who are gay or transgender, the Court concluded. But that reasoning applies only to Title VII, as Bostock itself and our subsequent cases make clear….

We recognize that other courts and judges have taken different approaches to these issues. We recognize, too, that several district courts have addressed similar laws in other States and assessed those laws in much the same way as the district court did in this case. And our thoughtful colleague has reached a similar conclusion. We appreciate their perspectives, and they give us pause. But they do not eliminate our doubts about the ultimate strength of the challengers’ claims for the reasons just given.

All told, the challengers lack a “clear showing” that they will succeed on the merits, and that is particularly so in view of the burdensome nature of a facial attack and the fraught task of justifying statewide relief….

Judge Helene White concurred in part (as to an injunction scope issue that I don’t discuss in this post) and dissenting in part:

Tennessee’s law likely discriminates against Plaintiffs on the basis of sex in violation of the Equal Protection Clause, thus triggering intermediate scrutiny. Although the state argues that the act “appl[ies] equally to males and females,” the law discriminates based on sex because “medical procedures that are permitted for a minor of one sex are prohibited for a minor of another sex.” To illustrate, under the law, a person identified male at birth could receive testosterone therapy to conform to a male identity, but a person identified female at birth could not. Indeed, until today, every federal court addressing similar laws reached the same conclusion as Brandt. {Defendants raise in their reply brief the argument that “[b]oth sexes use the same puberty blockers, so prohibiting them for gender dysphoria does not even consider sex.” Reply Br. 3. But this does not solve the problem. Under Tennessee’s law, someone identified male at birth could take puberty blockers consistent with a treatment plan that contemplates development consistent with a male identity, but someone identified female at birth could not.}

In the Title VII context, the Supreme Court has made clear that sex discrimination occurs when an “employer intentionally penalizes a person identified as male at birth for traits or actions that it tolerates in an employee identified as female at birth.” Bostock.  That principle is directly on point here and highly persuasive.

“Like racial classifications, sex-based discrimination is presumptively invalid.” “Government policies that discriminate based on sex cannot stand unless the government provides an ‘exceedingly persuasive justification,'” which requires showing that the “classification serves ‘important governmental objectives,’ and … is ‘substantially and directly related’ to the government’s objectives.” Applying this standard, I fail to see how the state can justify denying access to hormone therapies for treatment of minor Plaintiffs’ gender dysphoria while permitting access to others, especially in light of the district court’s robust factual findings on the benefits of these treatments for transgender youth….

Clark L. Hildabrand, Steven J. Griffin & Brooke A. Huppenthal of the Tennessee Attorney Generl’s office, Adam K. Mortara of Lawfair LLC, and Cameron T. Norris and Tiffany H. Bates of Consovoy McCarthy PLLC represent the state.

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