This section contains the nature of the case and procedural background.

In 1979, the World Professional Association for Transgender Health (WPATH) published clinical guidelines for treating gender dysphoria with sex transition treatments. They recognized the extensive and sometimes irreversible consequences of hormonal therapy and sex reassignment surgery and acknowledged that some individuals who undergo reassignment procedures later regret their decision to do so. Their standards of care provided that hormonal and surgical sex reassignment treatments should be administered only to adults. In 1998, WPATH revised its standards of care to permit healthcare professionals to administer puberty blockers and hormones to minors in “rare” circumstances. WPATH recognized that there is “limited data on the optimal timing” of sex transition treatments or “the long-term physical, psychological, and neurodevelopmental outcomes in youth.” The number of minors requesting sex transition treatments has increased. In the last three years, more than 20 States have enacted laws banning the provision of sex transition treatments to minors, while two have enacted near-total bans. Health authorities in a number of European countries have raised significant concerns regarding the potential harms associated with using puberty blockers and hormones to treat transgender minors. The process has been labeled as experimental, highly uncertain, with long-term risks largely unknown. In 2023, Tennessee restricted sex transition treatments for minors by enacting the Prohibition on Medical Procedures Performed on Minors Related to Sexual Identity, Senate Bill 1 (SB1). SB1 prohibits healthcare providers from prescribing, administering, or dispensing puberty blockers or hormones to any minor for the purpose of (1) enabling the minor to identify with, or live as, a purported identity inconsistent with the minor’s biological sex, or (2) treating purported discomfort or distress from a discordance between the minor’s biological sex and asserted identity. SB1 permits a healthcare provider to administer puberty blockers or hormones to treat a minor’s congenital defect, precocious puberty, disease, or physical injury. These prohibitions are intended to “protect minors from physical and emotional harm” by “encouraging minors to appreciate,” rather than “become disdainful of,” their sex. Ps challenged SB1 under the Equal Protection Clause of the Fourteenth Amendment. The District Court partially enjoined enforcement of SB1’s prohibitions. The court concluded that Ps lacked standing to challenge the law’s ban on sex transition surgery for minors. It held that Ps were likely to succeed on their equal protection challenge to the law’s prohibitions on puberty blockers and hormones. The court found that transgender individuals constitute a quasi-suspect class, that SB1 discriminates on the basis of sex and transgender status, and that SB1 was unlikely to survive intermediate scrutiny. The District Court issued a statewide injunction enjoining enforcement of all provisions of SB1 except for the private right of action and the law’s ban on sex transition surgery. The Sixth Circuit reversed. It found that SB1 does not classify on the basis of sex because the law “regulates sex-transition treatments for all minors, regardless of sex,” by prohibiting all minors from “receiv[ing] puberty blockers or hormones or surgery in order to transition from one sex to another.” The court declined to recognize transgender individuals as a suspect class, finding that transgender individuals are neither politically powerless nor a discrete group defined by obvious, immutable, or distinguishing characteristics. It held that SB1 was subject to and survived rational basis review, finding that D had offered “considerable evidence” regarding the risks associated with the banned medical treatments and the flaws in existing research. Ps appealed.

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