TN SB1 Complaint As Filed On 4.20.23
TN SB1 Complaint As Filed On 4.20.23
TN SB1 Complaint As Filed On 4.20.23
Plaintiffs,
v.
Defendants.
Plaintiffs, 1 by and through their attorneys, bring this Complaint against the above-named
PRELIMINARY STATEMENT
1. On March 2, 2023, Tennessee Governor Bill Lee signed into law Senate Bill 1,
codified in Tennessee Code Annotated § 68-33-101 et seq. (hereinafter the “Health Care Ban” or
“Ban”), which bans the provision of medically necessary and potentially lifesaving healthcare to
transgender adolescents. The law was passed over the sustained and robust opposition of medical
experts in Tennessee and across the country. It was also passed over the pleas of families across
Tennessee who urged lawmakers not to interfere in the medical decision-making of parents, their
minor children, and their doctors. Absent intervention by this Court, the law will go into effect on
July 1, 2023, disrupting or preventing medical care for hundreds of adolescents across Tennessee.
The Heath Care Ban violates the constitutional rights of Tennessee adolescents and their parents,
significant distress caused by incongruence between a person’s gender identity and the sex they
were designated at birth. All of the major medical associations in the United States recognize that
adolescents with gender dysphoria may require medical interventions to treat severe distress. For
instance, puberty-delaying treatment and hormone therapy are medically indicated to alleviate
severe distress associated with gender dysphoria, and for some older adolescents, chest surgery
may be medically necessary. In providing this medically necessary healthcare, sometimes referred
1
Plaintiffs John Doe, Jane Doe, James Doe, Ryan Roe, and Rebecca Roe have filed a separate
motion to proceed using these pseudonyms, rather than their legal names, in order to protect their
privacy regarding the minor plaintiffs’ transgender status and their medical condition and
treatment.
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to as “gender-affirming care,” medical providers are guided by widely accepted protocols for
3. The Health Care Ban interferes with the ability of doctors to follow these evidence-
dispensing any puberty blocker or hormone—from being performed “for the purpose of…
[e]nabling a minor to identify with” a gender identity different from the sex they were designated
at birth or “[t]reating purported discomfort or distress from a discordance between the minor’s sex
and asserted identity.” Tenn. Code Ann. § 68-33-103(a)(1)(A)–(B) (2023). In so doing, the Health
Care Ban denies adolescents medically necessary treatment and prevents parents from exercising
their fundamental rights to obtain medically necessary care for their adolescent children. It further
prohibits doctors from treating their patients in accordance with well-established standards of care
4. While the Health Care Ban purports to protect young people from risks allegedly
associated with the prohibited health care, decades of clinical experience and research have shown
that gender-affirming health care is safe, effective, and improves the health and well-being of
adolescents with gender dysphoria. Moreover, all of the treatments prohibited by the Health Care
Ban are permitted when undertaken for any reason other than to affirm a gender identity that differs
5. If the Health Care Ban goes into effect, it will have devastating consequences for
transgender youth and their families in Tennessee. Transgender adolescents with gender dysphoria
will be unable to obtain medical care that those who understand their medical needs—their doctors
and parents—agree is medically necessary. Untreated gender dysphoria is associated with severe
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harm including anxiety, depression, and suicidality. Cutting vulnerable adolescents off from
6. Some parents of transgender children are making plans to flee the State to protect
their children’s health and safety and to obtain the medical treatment their children need. Those
with the resources to do so will have to leave their jobs, businesses, extended families, and
communities. Others will have to shoulder the hardship of disruptive and expensive travel to
secure medical care for their children, often at the expense of the child’s time in school and the
parents’ time at work. Other families that do not have the resources or are otherwise unable to
leave or travel are terrified about what will happen if the law takes effect. For these parents and
hundreds of others across Tennessee, the Ban is creating a sense of desperation at the prospect of
watching their children’s suffering resume and symptoms possibly worsen as they lose access to
THE PARTIES
Samantha and Brian are the parents of L.W., their fifteen-year-old daughter. L.W. is transgender
and is currently receiving medically necessary care that would be prohibited by the Health Care
Ban.
9. Plaintiffs Ryan Roe and Rebecca Roe live in Tennessee. Rebecca is the parent of
Ryan Roe, her fifteen-year-old son. Ryan Roe is transgender and is currently receiving medically
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3. The Doe Family
10. Plaintiffs John Doe, Jane Doe, and James Doe live in Tennessee. Jane and James
Doe are the parents of John Doe, their twelve-year-old son. John Doe is transgender and is
currently receiving medically necessary care that would be prohibited by the Health Care Ban.
11. Plaintiffs L.W., Ryan Roe, and John Doe are collectively referred to herein as the
“Minor Plaintiffs.” Their parents, Samantha Williams, Brian Williams, Rebecca Roe, Jane Doe,
and James Doe are collectively referred to herein as the “Parent Plaintiffs.”
B. Provider Plaintiff
12. Plaintiff Dr. Susan Lacy (the “Provider Plaintiff”) is a physician licensed to practice
medicine in Tennessee. Dr. Lacy operates a private practice in Memphis, Tennessee, and she
provides gender-affirming care that would be prohibited by the Health Care Ban. She is bringing
C. Defendants
13. Defendant Jonathan Skrmetti is the Attorney General and Reporter of the State of
Tennessee. The Attorney General/Reporter is headquartered at 500 Dr. Martin Luther King Jr.
Blvd., Nashville, TN 37219, and has additional offices throughout Tennessee. Under the Health
Care Ban, Defendant Skrmetti is tasked with bringing legal actions against any “healthcare
provider that knowingly violates [the Health Care Ban].” Tenn. Code Ann. § 68-33-106(b). He is
also authorized to “establish a process by which violations of [the Health Care Ban] may be
reported.” Tenn. Code Ann. § 68-33-106(a). Defendant Skrmetti is sued in his official capacity.
14. Defendant Tennessee Department of Health (the “DOH”) is the primary agency of
the State of Tennessee responsible for all aspects of public health and provides health services to
many Tennesseans across the state. The DOH is headquartered at 710 James Robertson Parkway,
Nashville, TN 37243. Each county in Tennessee has a county health department, which operates
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under the direct supervision of the DOH. In 2014, roughly 1.4 million people were served by these
counties. The DOH is a “health program or activity” within the meaning of section 1557 of the
Patient Protection and Affordable Care Act (“ACA”), 42 U.S.C. § 18116 (“Section 1557”), and it
is a recipient of federal financial assistance, including grants, contracts, and other financial
assistance from the United States Department of Health and Human Services, as well as federal
Medicare and Medicaid funds. The Health Care Ban provides that any violation of the statute
expressly includes “[t]he department of health.” Tenn. Code Ann. §§ 68-33-102(2)(A), 107.
15. Defendant Ralph Alvarado, MD, FACP is the Commissioner of the DOH.
Defendant Alvarado oversees and directs the functions of the DOH, including the activities of
licensure regulation entities, such as the Tennessee Board of Medical Examiners, which is
“attached” to the DOH. Tenn. Code Ann. § 68-33-102. Defendant Alvarado is sued in his official
capacity.
“board…attached to the” DOH, Tenn. Code Ann. § 68-33-102(2)(B), with the power to license,
regulate and discipline health care providers within the State of Tennessee. The Medical Board is
headquartered at 710 James Robertson Parkway, Nashville, TN 37243. The Health Care Ban
provides that any violation of the statute “requires emergency action by an alleged violator’s
appropriate regulatory authority,” which expressly includes any “agency, board, council, or
committee attached to the department of health.” Tenn. Code Ann. §§ 68-33-102(2)(B), 107.
17. Defendant Melanie Blake, MD is the President of the Medical Board. Defendant
Stephen Loyd, MD is the Vice President of the Medical Board. Defendants Randall E. Pearson,
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MD; Phyllis E. Miller, MD; Samantha McLerran, MD; Keith G. Anderson, MD; Deborah
Christiansen, MD; John W. Hale, MD; John J. McGraw, MD; Robert Ellis; James Diaz-Barriga;
and Jennifer Claxton (collectively and together with Defendants Blake and Loyd, the “Medical
Board Defendants”) are members of the Medical Board. The Medical Board Defendants are sued
18. Defendant Logan Grant is the Executive Director of the Tennessee Health Facilities
headquartered at 665 Mainstream Drive, 2nd Floor, Nashville, TN 37243, and has additional
offices throughout Tennessee. The Health Facilities Commission is an agency of the State of
Tennessee with responsibility for, among other things, conducting investigations of health care
facilities in Tennessee to ensure compliance with state and federal regulations. The Health Care
Ban provides that any violation of the statute “requires emergency action by an alleged violator’s
appropriate regulatory authority,” which expressly includes “[t]he health facilities commission.”
Tenn. Code Ann. §§ 68-33-102(2)(C), 107. Defendant Grant is sued in his official capacity.
19. Defendant Skrmetti, Defendant Alvarado, the Medical Board Defendants, and
Defendant Grant (collectively, the “State Official Defendants”) are all governmental actors and/or
employees acting under color of State law for purposes of 42 U.S.C. § 1983 and the Fourteenth
Amendment. Defendants are therefore liable for both their violation of the right to equal protection
and for their violation of Parent Plaintiffs’ fundamental rights under 42 U.S.C. § 1983.
20. This action arises under the U.S. Constitution, 42 U.S.C. § 1983, and 42 U.S.C.
§ 18116(a).
21. This Court has subject matter jurisdiction pursuant to Article III of the U.S.
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22. This Court is authorized to issue a declaratory judgment pursuant to 28 U.S.C.
23. Venue in this district is proper pursuant to 28 U.S.C. § 1391(b)(1) and (b)(2),
because one or more Defendants reside in this district and because a substantial part of the events
FACTUAL BACKGROUND
24. Gender identity refers to a person’s core sense of belonging to a particular gender,
25. Living in a manner consistent with one’s gender identity is critical to the health and
26. Although the precise origin of gender identity is unknown, a person’s gender
identity is a fundamental aspect of human development. There is a general medical consensus that
medical intervention.
28. A person’s gender identity usually matches the sex they were designated at birth
based on the appearance of their external genitalia. The terms “sex designated at birth” or “sex
assigned at birth” are more precise than the term “biological sex” because all of the physiological
aspects of a person’s sex are not always aligned with each other. For these reasons, the Endocrine
and clinicians, warns practitioners that the terms “biological sex” and “biological male or female”
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29. Most boys are designated male at birth based on their external genital anatomy, and
most girls are designated female at birth based on their external genital anatomy. But transgender
people have a gender identity that differs from the sex they were designated at birth. A transgender
boy or man is someone who has a male gender identity but was designated a female sex at birth.
A transgender girl or woman is someone who has a female gender identity but was designated a
30. Gender dysphoria is the clinical diagnosis for the significant distress that results
from the incongruity between one’s gender identity and sex they were designated at birth. It is a
serious medical condition, and it is codified in the American Psychiatric Association’s Diagnostic
and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) (DSM-5
31. Being transgender is not itself a medical condition to be cured. But gender
dysphoria is a serious medical condition that, if left untreated, can result in debilitating anxiety,
32. The World Professional Association for Transgender Health (“WPATH”) has
issued Standards of Care for the Health of Transgender and Gender Diverse People (“WPATH
Standards of Care” or “SOC 8”) since 1979. The current version is SOC 8, published in 2022.
The WPATH Standards of Care provide guidelines for multidisciplinary care of transgender
individuals, including children and adolescents, and describe criteria for medical interventions to
when medically indicated—for adolescents and adults. Every major medical organization in the
United States recognizes that these treatments can be medically necessary to treat gender
dysphoria.
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33. The SOC 8 is based upon a rigorous and methodological evidence-based approach.
Its recommendations are informed by a systematic review of evidence and an assessment of the
benefits and harms of alternative care options, as well as expert consensus. The SOC 8
Academies of Medicine and the World Health Organization. SOC 8’s recommendations were
Evaluations) methodology considering the available evidence supporting interventions, risks and
34. A clinical practice guideline from the Endocrine Society (the “Endocrine Society
Guideline”) provides protocols for the medically necessary treatment of gender dysphoria similar
35. The guidelines for the treatment of gender dysphoria outlined in the WPATH
Standards of Care and in the Endocrine Society Guideline are comparable to guidelines that
36. Doctors in Tennessee and throughout the country follow these widely accepted
37. Medical guidance to clinicians differs depending on whether the treatment is for a
pre-pubertal child, an adolescent, or an adult. In all cases, the precise treatment recommended for
38. Before puberty, gender-affirming care does not include any pharmaceutical or
surgical intervention. Care for pre-pubertal children may include “social transition,” which means
supporting a child living consistently with the child’s persistently expressed gender identity. Such
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care might include support around adopting a new name and pronouns, wearing clothes that feel
39. Under SOC 8 and the Endocrine Society Guideline, medical interventions may
become medically necessary and appropriate as transgender youth reach puberty. In providing
medical treatments to adolescents, pediatric endocrinologists and other clinicians work with
qualified mental health professionals experienced in diagnosing and treating gender dysphoria.
1. Puberty-Delaying Treatment
40. For many transgender adolescents, going through puberty in accordance with the
sex designated to them at birth can cause extreme distress. For these adolescents, puberty-delaying
potentially prevent the heightened gender dysphoria and permanent, unwanted physical changes
41. Under the Endocrine Society Guideline, transgender adolescents may be eligible
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• The adolescent:
o has been informed of the effects and side effects of treatment (including
potential loss of fertility if the individual subsequently continues with sex
hormone treatment) and options to preserve fertility; and
o has given informed consent, and (particularly when the adolescent has not
reached the age of legal medical consent, depending on applicable law) the
parents or other caretakers or guardians have consented to the treatment and
are involved in supporting the adolescent throughout the treatment process.
42. Puberty-delaying treatment has been shown to be safe and effective at treating
stage of pubertal development that the person is in at the time of treatment. For transgender girls,
this treatment pauses the physiological changes typical of male puberty and prevents the
development of associated secondary sex characteristics like facial hair and a pronounced “Adam’s
apple.” It also prevents the deepening of the young person’s voice and genital growth. For
menstruation. The use of these interventions after the onset of puberty can eliminate or reduce the
need for surgery later in life. If gender-affirming hormones are prescribed to initiate hormonal
puberty consistent with gender identity after puberty-delaying treatment, transgender adolescents
will develop secondary sex characteristics typical of peers with their gender identity.
44. On its own, puberty-delaying treatment does not permanently affect fertility.
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45. Because puberty-delaying treatment followed by gender-affirming hormone
therapy can affect fertility, patients are counseled about the risks and benefits of treatment and
and no gender-affirming hormone therapy is provided, there are no lasting effects of treatment.
Endogenous puberty resumes and patients undergo puberty in a timeline typical of their peers.
treatment, patients undergo puberty consistent with their gender identity on a timeline typical of
their peers.
2. Hormone Therapy
48. For some adolescents, it may be medically necessary and appropriate to treat their
gender dysphoria with gender-affirming hormone therapy (testosterone for transgender boys, and
49. Under the Endocrine Society Guideline, transgender adolescents may be eligible
• The adolescent:
o has been informed of the partly irreversible effects and side effects of
treatment (including potential loss of fertility and options to preserve
fertility);
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o the adolescent has sufficient mental capacity to estimate the consequences
of this (partly) irreversible treatment, weigh the benefits and risks, and give
informed consent to the treatment; and
o has given informed consent, and (particularly when the adolescent has not
reached the age of legal medical consent, depending on applicable laws) the
parents or other caretakers or guardians have consented to the treatment and
are involved in supporting the adolescent throughout the treatment process.
50. For transgender boys, hormone therapy involves treatment with testosterone and
therapy has been shown to be safe and effective at treating gender dysphoria in adolescents.
52. Side effects from gender-affirming hormone therapy are rare when treatment is
after a comprehensive psychosocial assessment by a qualified health professional who: (i) assesses
for the diagnosis of gender dysphoria and any other co-occurring diagnoses, (ii) ensures the child
can assent and the parents/guardians can consent to the relevant intervention after a thorough
review of the risks, benefits, and alternatives of the intervention, and (iii) ensures that, if co-
occurring mental health conditions are present, they do not interfere with the accuracy of the
diagnosis of gender dysphoria or impair the ability of the adolescent to assent to care.
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B. The General Assembly’s Passage of the Health Care Ban
54. On February 23, 2023, the Tennessee General Assembly passed the Health Care
“[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.” Tenn. Code Ann. § 68-33-103(a)(1). The Ban also prohibits “any person”
from “knowingly” providing “hormone therapy” or “puberty blocker[s]” to a minor in any manner
not in compliance with the provisions of the Ban. Tenn. Code Ann. § 68-33-104. The Ban defines
“medical procedure” broadly, such that the term means: “(A) Surgically removing, modifying,
altering, or entering into tissues, cavities, or organs of a human being; or (B) Prescribing,
administering, or dispensing any puberty blocker or hormone to a human being.” Tenn. Code Ann.
reproductive system that define the individual as male or female, as determined by anatomy and
55. The Ban includes a phase-out period, which allows health care providers to
continue to provide medical procedures proscribed in the Ban if “the medical procedure on the
minor began prior to the effective date of this act [July 1, 2023] and concludes on or before March
31, 2024.” Tenn. Code Ann § 68-33-103(b)(1)(B). The Ban does not allow the initiation of new
56. The Ban states that healthcare professionals who provide or offer to provide such
procedures are subject to professional discipline by the appropriate regulatory agency, Tenn. Code
Ann. § 68-33-107, and may be sued by the Attorney General and Reporter or private parties, Tenn.
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57. The General Assembly declared that the Ban was necessary to “protect the health
and welfare of minors,” Tenn. Code Ann. § 68-33-101(a), despite the banned medical treatment
being part of well-established standards of care for the treatment of gender dysphoria in
adolescents.
58. The General Assembly rejected an amendment to the Ban that would have banned
surgical procedures, but not gender-affirming medication, for minors for the purpose of
“[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
59. The General Assembly also rejected amendments to the Ban that would have
banned all cosmetic surgeries conducted on minors, regardless of the purpose for which the minor
60. The General Assembly passed the Ban despite hearing testimony from Tennessee
doctors about the lifesaving benefits of the banned care for their patients and the grave harm to
their patients’ health and well-being if they are prohibited from receiving this care. This included
testimony about the high rate of suicide attempts by transgender adolescents as well as detailed
explanations of the rigorous standards of diagnosis and treatment doctors follow when providing
61. Not a single doctor with experience treating transgender youth testified in support
of the bill. The only doctor who did testify in support likened “greater awareness of and education
compared gender-affirming care for transgender youth to removing the leg and an eye of a minor
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62. The General Assembly passed the Ban despite hearing testimony from transgender
Tennesseans who shared their experiences of years of struggle, feelings of hopelessness, and desire
to end their lives prior to receiving gender-affirming care and the positive and transformational
impact that gender-affirming medical treatment had on their health and overall well-being.
63. The General Assembly also passed the Ban despite hearing testimony of parents of
transgender children with gender dysphoria, who pleaded with lawmakers not to risk their
children’s health by stripping them of the medical care that enables them to thrive. Multiple
parents spoke about the torture in wondering whether their child would die by suicide prior to
gender-affirming treatment, and then the relief that came from watching their child’s despair lessen
64. At various points during legislative debates, proponents of the Ban within the
General Assembly defended the bill based on general criticisms and stereotypes of transgender
people. The sponsor of the House companion bill described practitioners who provide gender-
affirming care as “indulging the child’s perception of his or her sex.” A co-sponsor of the House
bill expressed that being transgender was a “fiction” and a “fantasy.” Addressing trans youth in
Tennessee, one House member referenced the views of his preacher, stating: “If you don’t know
what you are, a boy or girl, male or female, just go in the bathroom and take your clothes off and
65. The Health Care Ban is just one piece of a robust discriminatory legislative agenda
targeting transgender persons. In addition to the Health Care Ban, the Senate has already passed
three other bills this legislative session that focused on transgender people; the House has passed
one of these bills, and the other two are pending. The bill that passed in both bodies of the General
Assembly and will go into effect if signed into law by Governor Lee, SB1237/HB0306, allows
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private schools to ban transgender students from participation in athletic activities. Another bill
pending in the General Assembly, SB1440, defines “sex” in the Tennessee Code to be the
“immutable biological sex as determined by anatomy and genetics existing at the time of birth”
and the “sex listed on the person’s original birth certificate.” SB466, also being considered, states
that teachers are not required to use a transgender student’s preferred pronouns. Both chambers
are also considering bills (HB1215 and SB1339) that would block TennCare, Tennessee’s
Medicaid program, from reimbursing providers for gender-affirming care for all transgender
66. The Health Care Ban prohibits the use of well-established treatments for gender
(testosterone for transgender boys, and estrogen and testosterone suppressants for transgender
girls), and chest surgery—because these treatments are provided “for the purpose of” “[e]nabling
a minor to identify with” a gender identity different from the sex they were designated at birth or
“[t]reating purported discomfort or distress from a discordance between the minor’s sex and
asserted identity.” Tenn. Code Ann. § 68-33-103(a)(1). The Ban permits the use of these same
precocious puberty. Central precocious puberty is the premature initiation of puberty by the central
nervous system—before 8 years of age in people designated female at birth and before 9 years of
age in people designated male. When untreated, central precocious puberty can lead to the
impairment of final adult height as well as antisocial behavior and lower academic achievement.
The Health Care Ban permits puberty-delaying treatment for central precocious puberty because
it is not provided for purposes of “[e]nabling a minor to identify with” a gender identity different
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from the sex designated at birth or “[t]reating purported discomfort or distress from a discordance
between the minor’s sex and asserted identity.” Tenn. Code Ann. § 68-33-103(a)(1).
68. Likewise, the Health Care Ban prohibits hormone therapy when the treatment is
used to treat transgender adolescents with gender dysphoria but allows that same hormone therapy
when prescribed to non-transgender patients. For example, non-transgender boys with delayed
puberty may be prescribed testosterone if they have not begun puberty by 14 years of age. Without
testosterone, for most of these patients, puberty would eventually initiate naturally. However,
testosterone is prescribed to avoid some of the social stigma that comes from undergoing puberty
later than one’s peers and failing to develop the secondary sex characteristics consistent with their
gender at the same time as their peers. Likewise, non-transgender girls with primary ovarian
condition that can cause a failure of ovaries to develop) may be treated with estrogen. Moreover,
non-transgender girls with polycystic ovarian syndrome (a condition that can cause increased
testosterone and, as a result, symptoms including facial hair) may be treated with testosterone
suppressants.
69. The side effects of the proscribed treatments are comparable when used to treat
gender dysphoria and when used to treat other conditions. In each circumstance, doctors advise
patients and their parents about the risks and benefits of treatment and tailor recommendations to
the individual patient’s needs. For adolescents, parents consent to treatment and the patient gives
their assent.
70. In passing the Health Care Ban, the General Assembly’s findings cited a purported
need to “protect[] minors from physical and emotional harm,” “protect[] the ability of minors to
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develop into adults who can create children of their own,” “promot[e] the dignity of minors,”
“encourage[e] minors to appreciate their sex, particularly as they undergo puberty,” and “protect[]
provide gender-affirming care to treat transgender adolescents when the same care is allowed for
other purposes.
72. The banned treatment is supported by a substantial body of research and clinical
73. The body of research supporting the safety and efficacy of the banned care is
comparable to the research supporting other treatments, but only gender-affirming medical care
74. Clinicians, including clinicians in Tennessee, have documented the safety and
75. Even if the banned treatments were “experimental in nature” (which they are not),
experimental treatments are permitted in Tennessee and are not banned. Wrongly labelling
gender-affirming care as “experimental” cannot justify categorically banning only this one form
76. The law bans the only evidence-based treatments for gender dysphoria in
adolescents.
77. The General Assembly’s purported interest in protecting minors from potential
physical and emotional risks associated with the prohibited medical care likewise cannot justify
the Health Care Ban. The majority of potential risks and side effects related to puberty-delaying
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treatment, hormone therapy, and chest surgeries for gender dysphoria are comparable to those risks
and side effects when such treatments are used for other indications. Further, Tennessee does not
ban other forms of care carrying similar risks, such as treatments that carry fertility risks.
78. Every medical intervention carries potential risks and potential benefits. Weighing
the potential benefits and risks of the treatment for gender dysphoria is a prudential judgment
similar to other judgments made by healthcare providers, adolescent patients, and their parents.
Adolescent patients and their parents often make decisions about treatments with less evidence
and/or greater risks than the treatments prohibited by the Health Care Ban.
79. The current standards of care for treating gender dysphoria in minors are consistent
with general ethical principles of informed consent. Existing clinical practice guidelines for
providers extensively discuss the potential benefits, risks, and alternatives to treatment, and
providers’ recommendations regarding the timing of interventions are based in part on the
80. There is nothing unique about any of the medically accepted treatments for
adolescents with gender dysphoria that justify singling out these treatments for prohibition based
on the concern about adolescents’ inabilities to assent or their parents’ inabilities to consent.
81. The Health Care Ban subjects medical care for transgender adolescents with gender
dysphoria to a double standard. The law singles out such care for sweeping prohibitions while
permitting the same medical treatments carrying the same potential risks when prescribed to treat
E. The Health Care Ban Will Cause Severe Harm to Transgender Youth
dysphoria when it is medically indicated puts them at risk of severe irreversible harm to their health
and well-being.
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83. Adolescents with untreated gender dysphoria can suffer serious medical
consequences, including possible self-harm and suicidal ideation. In one survey, more than half
of transgender youth who participated had seriously contemplated suicide. Studies have found
that as many as 40% of transgender people have attempted suicide at some point in their lives.
84. When adolescents are able to access puberty-delaying medication and hormone
therapy, their distress recedes and their mental health improves. Both clinical experience and
medical studies confirm that, for many young people, this treatment is transformative, and they go
85. The effects of undergoing one’s endogenous puberty may not be reversible even
with subsequent hormone therapy and surgery in adulthood, thus exacerbating lifelong gender
dysphoria in adolescent patients who are unable to access gender-affirming medical care. For
instance, bodily changes from puberty as to stature, bone structure, genital growth, voice, and
86. Medical treatment in adolescence can reduce life-long gender dysphoria, possibly
eliminating the need for surgical intervention in adulthood, and can improve mental health
outcomes significantly.
experiencing gender dysphoria. The major medical and mental health associations support the
provision of such care and recognize that the mental and physical health benefits to receiving this
care outweigh the risks. These groups include the American Academy of Pediatrics, American
Medical Association, the Endocrine Society, the Pediatric Endocrine Society, the American
Psychological Association, the American Academy of Family Physicians, the American College
of Obstetricians and Gynecologists, the National Association of Social Workers, and WPATH.
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F. The Impact of the Health Care Ban on Plaintiffs
88. L.W. is a fifteen-year-old girl, a freshman in high school, and has lived in
Tennessee her entire life. When she is not at school, she likes playing video games, listening to
89. Here is a photo of L.W. with her mother Samantha Williams, and her father Brian
Williams.
90. L.W. is transgender. She is a girl with a female gender identity, but when she was
91. Growing up, L.W. felt uncomfortable in her body. She remembers feeling like she
was drowning and trapped in the wrong body. She avoided changing clothes in front of anyone,
tried to hide her body behind baggy clothing, and was not comfortable hugging her family.
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92. Before she understood what she was feeling, L.W. experienced significant stress
and anxiety. The discomfort of using the boys’ restroom at school would cause her to avoid using
the restroom altogether and led to her developing urinary tract infections. She had trouble focusing
at school. She could not connect with her friends. Her anxiety was constant.
93. In 2019, an extended family member came out as transgender, and L.W. began to
realize she was feeling the same way as her family member described feeling. L.W. started doing
her own research about what it meant to be transgender and began her social transition by telling
94. It took L.W. a little while to build up the courage to talk to her parents about being
transgender. She was incredibly nervous about what their reaction would be. She first told her
mother in November 2020. L.W.’s mother had a lot of questions, but was supportive of her
daughter and told L.W. that she and L.W.’s father would always love her. L.W. came out to her
father and brother shortly after. She finally felt like she could talk about and be who she was with
them.
95. At first, L.W. asked her family to use “they” and “them” pronouns because she
thought she might be non-binary, a term commonly used by individuals whose gender identity is
neither male nor female. However, after exploring her gender identity more, she asked her family
to use “she” and “her.” At this time, she began growing her hair long and wore girls’ clothes,
96. A few months after L.W. came out as transgender to her parents, she asked them to
take her to see a doctor to talk about being transgender and medical treatments that might help
address her dysphoria. L.W.’s parents first found her a therapist so that she could discuss what
she was feeling with a mental health professional. In December 2020, L.W. started seeing a
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therapist, who conducted a mental health assessment and diagnosed her with gender dysphoria.
97. In June 2021, at the recommendation of L.W.’s pediatrician and therapist, L.W.’s
parents took her to Vanderbilt Children’s Hospital, where she met with a team of doctors who
informed L.W. and her parents about medications L.W. could take to stop male puberty. This was
a relief to L.W., who worried that her gender dysphoria would get worse if she were to undergo
male puberty. After undergoing various tests and learning about the risks and possible side effects,
L.W. and her parents consented to L.W. starting to take puberty-delaying medications.
98. The medication made a big difference for L.W. She no longer felt fear and anxiety
about her body changing in ways inconsistent with her gender, which greatly improved her mental
health.
99. L.W. told her classmates and teachers in January 2022 that her name is “L.,” that
she is a girl, and that her pronouns are “she” and “her.” L.W.’s school is very supportive of her.
100. After taking puberty-delaying medication for more than a year, undergoing
additional evaluations, and assessing the potential risks and side effects of treatment with her
family, L.W. began estrogen hormone therapy so that her body would undergo feminine pubertal
changes. L.W.’s family monitors her physical and mental health and brings her to Vanderbilt for
101. Since beginning gender-affirming treatment, L.W. no longer experiences the “near-
constant feeling” of gender dysphoria, feels more confident and comfortable, and gives and accepts
hugs from her family. Her mother has noticed a huge change in her daughter, who is now outgoing
and thriving. L.W. looks forward to a future where she continues receiving the treatment she needs
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102. L.W. and her family are afraid of the impact the Health Care Ban will have on L.W.
and her family if it goes into effect. L.W. is scared that losing access to her medication, which she
has been taking for almost two years, will mean that her body will undergo unwanted, permanent
changes that are inconsistent with her gender identity. Her mother worries about the debilitating
stress and anxiety associated with L.W.’s gender dysphoria returning if she loses access to gender-
affirming care. Beginning on July 1, 2023, if L.W. is to receive medication in Tennessee, her
medication will be titrated down in preparation for the cutoff imposed by the Ban.
103. L.W. has spent her entire life in Tennessee; her school, friends, and family are in
Tennessee. Her parents have jobs that they love in Tennessee. However, L.W. and her family are
concerned about L.W.’s health and well-being if she can no longer receive the medical care she
needs in Tennessee. They have discussed needing to leave Tennessee so that L.W. can get the
104. Ryan Roe is fifteen years old and in his freshman year of high school, where his
favorite subjects are math and science. Outside school, he likes exploring cafes and coffee shops
105. Ryan is a boy. Ryan is also transgender. He has a male gender identity, but when
106. Ryan knew from a young age that he did not feel comfortable with his designation
as a girl. As he approached puberty, Ryan experienced more anxiety about his body changing in
feminine ways.
107. In fifth grade, when Ryan started to go through puberty, he tried to find ways to
cover up his body by wearing baggy clothes. He chose to wear boys’ clothes and cut his hair short.
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108. When Ryan got his period in fifth grade, he had a panic attack because “everything
felt wrong about living in [his] body.” His anxiety and distress confirmed for him that he is
109. When Ryan told his mother, Rebecca Roe, that he was transgender, she did not
understand what it meant to be transgender, but she was scared that her son would be discriminated
110. Rebecca wanted to make sure Ryan had appropriate mental health support, and he
111. Although Ryan met with his therapist, he continued to experience anxiety and
discomfort about his body. It reached the point that he barely spoke in public and would not
112. His anxiety grew so severe that he went through a period of time when he would
113. In the summer before eighth grade, Ryan’s therapist diagnosed him with gender
dysphoria. With his distress worsening, Rebecca took Ryan to Vanderbilt Children’s Hospital to
meet with doctors about treatment options for his gender dysphoria. During his first visit to
Vanderbilt, the doctors determined that he was too far into puberty for puberty-delaying
medication. He was prescribed medication to stop his period, which was a source of significant
distress.
114. The doctors at Vanderbilt also provided Rebecca and Ryan with information about
gender-affirming testosterone treatment. At home, the Roes discussed the treatment, including all
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115. In January 2022, Rebecca and Ryan went back to Vanderbilt for a follow-up
appointment to discuss the initiation of testosterone. At that appointment, the Vanderbilt providers
discussed the risks and benefits of treatment with the Roes, conducted tests, and determined that
Ryan would benefit from the initiation of testosterone. Rebecca consented to the treatment and
Ryan began testosterone after that visit. In Rebecca’s words, the process of beginning testosterone
“was the most deliberate and careful medical process” that the Roes had ever been through for
Ryan.
117. Ryan has been receiving hormone therapy for more than a year. This treatment has
given him hope and a positive outlook on the world. As his body has undergone physiological
changes that align with who he is, his confidence and comfort have grown. He participates in class
again and no longer feels anxious by the sound of his own voice. As a result of the hormone
therapy, Ryan feels more comfortable in his own skin and likes looking at himself in the mirror
and in photos.
118. Due to the Health Care Ban, Rebecca and Ryan were informed by Vanderbilt that
they would no longer be providing treatment to current patients under the age of 18 beginning on
July 1, 2023. If Ryan is to receive medication in Tennessee after July 1, 2023, his medication will
119. Rebecca began to call around to providers in other states, but many have long
waitlists, and traveling out of state to continue treatment will be costly and difficult.
120. It is not an option for Ryan to discontinue the medical treatment that has saved his
life. He is terrified of going back to a time when he does not have access to this care. The prospect
of losing access to gender-affirming medical care has caused both Ryan and his parents enormous
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stress. Ryan’s biggest fear is that losing access to gender-affirming healthcare will have a serious
negative effect on his mental health. He is not sure if he will survive not being able to continue
receiving the treatment that allows him to live in a way consistent with his gender.
121. To enable Ryan’s access to the medical care that has changed his life, Ryan and
his family have discussed traveling, or even moving, out of state if the Health Care Ban goes into
effect. Ryan feels terrible that his family would need to move so that he could continue his care
and feels like he is losing his childhood by constantly needing to worry about how to access
gender-affirming care.
122. John Doe is twelve years old, and has lived in Tennessee for his entire life. He is
in sixth grade and enjoys playing guitar, baseball, and virtual reality games.
123. John is a boy. He is also transgender. John has a male gender identity, but when
124. From a very early age, John remembers getting very upset when people treated him
as a girl. He cried when his parents tried to make him wear dresses, he did not want to play with
dolls or dress-up like girls his age, and he wanted to wear the boys’ costumes in his dance recitals.
John repeatedly told his mother, Jane Doe, that he wanted to be a boy.
125. Before John began second grade, John’s mother contacted a local LGBTQ resource
center who connected them with a therapist. This therapist diagnosed John with gender dysphoria.
John has regularly seen this therapist for sessions over the past five years.
126. By second grade, John had begun his social transition. John had chosen a typically
male name for himself when he was younger. Having his parents use his chosen name made John
feel amazing, and he knew he wanted things to stay that way forever. As part of his transition,
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John also told his classmates and teachers that he is a boy. Subsequently, John’s parents obtained
a court order updating John’s legal name to reflect his chosen name.
127. As John learned about female puberty, he became upset thinking about the
possibility of those changes happening to his body. His mother told him about medication that
could prevent these changes, and John told her he wanted to explore receiving this medication.
discussing treatment options for his gender dysphoria. For two years, the doctors at Vanderbilt
monitored John and discussed the risks, benefits, and side effects of medication with John and his
family.
129. Eventually, doctors prescribed John with medication to delay puberty. John says
that taking this medication has made him much more comfortable at school and around others. As
soon as his doctors decide he is ready, John will begin taking testosterone so that he can continue
130. The idea of losing access to his medication is horrifying to John. He cannot imagine
losing control of his life for the next six years and fears permanent changes to his body if he
undergoes the wrong puberty. His parents fear for John’s safety as a transgender individual should
131. John’s endocrinologist has informed his family that despite the phase-out provision
in the law, she cannot continue providing the same puberty-delaying care that he currently receives
after July 1, 2023. She informed the family that her understanding is that the law allows her to do
nothing more than wean patients off their care beginning July 1, 2023. Because the endocrinologist
believes that reducing the dosage of John’s medication would be inappropriate and harmful to him,
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132. John’s parents have begun researching out-of-state options for John to receive care,
but are concerned about cost, disruption, and insurance coverage issues should they need to resort
to these drastic options to ensure their child receives necessary medical care. They have considered
moving out of state, but do not want to uproot their lives, and John’s, and move away from the
133. Dr. Lacy is a physician licensed to practice medicine in Tennessee. She graduated
from Johns Hopkins Medical School in 1993. Following medical school, Dr. Lacy completed
134. Dr. Lacy is bringing her claims on behalf of herself and her patients.
135. Dr. Lacy operates a private practice in Memphis, Tennessee, which provides
healthcare services to cisgender and transgender people. As part of her practice, Dr. Lacy provides
for patients with gender dysphoria, fertility services, and reproductive healthcare. Dr. Lacy treats
post-pubertal, transgender patients from ages 16 and up with hormone therapy. For transgender
children who have not yet started puberty, she refers parents to a pediatric endocrinologist that
136. Dr. Lacy currently treats 350-400 transgender patients. Of those 350-400 patients,
twenty patients are currently under age 18. Sixteen other patients were minors when Dr. Lacy
137. Dr. Lacy treats minor transgender patients in accordance with well-established
standards of care.
138. Between 2016 and 2019, Dr. Lacy worked at a clinic providing similar services to
her current practice where she treated between 100-200 transgender patients with gender
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dysphoria. When Dr. Lacy began to treat patients with hormone therapy for gender dysphoria in
2016, she had over 15 years of experience prescribing the same hormones to cisgender patients as
139. At Dr. Lacy’s current practice, she prescribes and administers the same medications
hormonal contraception—to her cisgender patients. For example, Dr. Lacy provides hormonal
contraception, which can be used to control one’s menstrual cycle and/or for ovulation
suppression, to cisgender patients who might have heavy periods. To treat hormonal issues in
cisgender women who are pre-menopausal or cisgender men who are approaching andropause
(declining levels of testosterone), Dr. Lacy also utilizes hormone therapy to maintain hormones
within the typical range for the patient’s gender. Additionally, medications used to suppress
testosterone can be used to address symptoms of polycystic ovarian syndrome, which can include
unwanted facial hair and body hair, excessive sweating, and body odor in cisgender woman.
140. If the Health Care Ban takes effect, Dr. Lacy will be prohibited from proving these
treatments to her transgender patients because they relate to “discordance between the minor’s sex
and asserted identity,” but she will be able to continue providing the same treatments to her non-
transgender patients.
141. If the Health Care Ban takes effect, Dr. Lacy will be required to either fully comply
with the law and therefore abandon her patients, or risk losing her medical license, which will
deprive her of the ability to care for all of her patients and negatively impact her livelihood.
Moreover, the Ban will place Dr. Lacy in direct conflict with the accepted, evidence-based
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142. As a medical provider of patients who experience gender dysphoria, Dr. Lacy has
developed a close relationship with both her patients and their families. Seeking and receiving
treatment for gender dysphoria is a profoundly personal and informed decision based on a person’s
innermost sense of self and individual needs. It is also a subject that remains very misunderstood
by the public at large. Many of her patients therefore require complete privacy, and Dr. Lacy
believes that, as a medical provider, it is her duty and obligation to advocate on behalf of her
143. Dr. Lacy knows from personal experience in treating hundreds of adolescents with
gender dysphoria that the Health Care Ban, if permitted to take effect, will significantly
compromise the health and well-being of her patients. Dr. Lacy is concerned that if transgender
youth cannot access hormone therapy through healthcare providers, some may resort to other
methods of accessing care that include buying medication from unauthorized suppliers and using
medication that they get from friends. This can lead to transgender adolescents taking the incorrect
dosage, and some will not have their hormone levels monitored through lab work, which is vital
144. Dr. Lacy is already seeing the impact of the Health Care Ban on access to hormone
therapy. She has observed firsthand the Health Care Ban placing undue stress and pressure on
transgender adolescents and their families looking to begin medical treatment, since patients fear
that if they have not begun care by the law’s arbitrary deadline, they will be cut off from access
altogether. If the Health Care Ban goes into effect on July 1, 2023, Dr. Lacy will be barred from
providing hormone therapy to treat gender dysphoria in her adolescent patients. In addition, she
will be required to stop providing hormone therapy to her adolescent patients who are already
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145. Dr. Lacy is deeply concerned for her young transgender patients because her
experience leads her to believe that denying her patients access to gender-affirming hormone
CAUSES OF ACTION
146. The Health Care Ban violates the Equal Protection Clause of the Fourteenth
Amendment because it discriminates on the basis of sex and transgender status by prohibiting
certain medical treatments only for transgender patients and only when those treatments are
performed “for the purpose of . . . [e]nabling a minor to identify with, or live as,” a gender identity
other than the sex designated at birth. Tenn. Code Ann. § 68-33-103(a)(1). This discrimination
cannot be justified under heightened scrutiny—or, indeed, under any level of scrutiny applicable
to equal protection claims. The Health Care Ban also infringes on the fundamental rights of parents
guaranteed by the Due Process Clause of the Fourteenth Amendment by preventing parents from
seeking appropriate medical care for their children. None of the statute’s purported justifications
for infringing on parents’ fundamental rights withstands heightened scrutiny or even rational basis
review.
147. The Health Care Ban also runs afoul of Section 1557 of the ACA in two distinct
ways. First, the Health Care Ban conflicts with the ACA. The ACA prohibits healthcare providers
from discriminating on the basis of sex. But the Health Care Ban requires that providers
discriminate on the basis of sex. The result is that providers such as Dr. Lacy must choose between
violating federal law (by failing to provide care) and violating state law (by providing care). The
Health Care Ban is therefore preempted by the ACA and the State Official Defendants should be
enjoined from enforcing it. Second, the ACA bars entities which receive federal financial
assistance, such as the DOH (and its sub-agencies, such as the Medical Board), from engaging in
discrimination on the basis of sex. But the Health Care Ban requires that the DOH and the Medical
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Board take “emergency action” to remedy any violation of the Health Care Ban, thus requiring
them to engage in discrimination on the basis of sex to the substantial detriment of the Plaintiffs
who are unable to receive or provide medical care. The Plaintiffs are therefore entitled to an order
prohibiting the DOH and the Medical Board from complying with the Health Care Ban unless and
COUNT ONE
THE HEALTH CARE BAN VIOLATES THE
FOURTEENTH AMENDMENT’S GUARANTEE OF
EQUAL PROTECTION UNDER THE LAW
(ALL PLAINTIFFS AGAINST STATE OFFICIAL DEFENDANTS)
148. Plaintiffs repeat and reallege each and every allegation contained in paragraphs 1
149. State Official Defendants are all governmental actors and/or employees acting
under color of State law for purposes of 42 U.S.C. § 1983 and the Fourteenth Amendment.
150. The Equal Protection Clause of the Fourteenth Amendment to the United States
Constitution, enforceable pursuant to 42 U.S.C. § 1983, provides that no State shall “deny to any
person within its jurisdiction the equal protection of the laws.” U.S. Const. amend. XIV, § 1.
151. The Health Care Ban bars the provision of various forms of medically necessary
care only when the care is “for the purpose of…[e]nabling a minor to identify with, or live as,” a
gender identity different from their sex designated at birth or “[t]reating purported discomfort or
distress from a discordance between the minor’s sex and asserted identity.” Tenn. Code Ann. § 68-
33-103(a)(1). It permits the use of these same treatments for any other purpose. Tenn. Code Ann.
§ 68-33-103(b)(1)(A).
152. In doing so, the Ban explicitly discriminates against transgender adolescents,
including the Minor Plaintiffs and the patients cared for by the Provider Plaintiff, based on their
transgender status and sex, including their failure to conform to stereotypes and expected behavior
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associated with their sex designated at birth. The Ban also discriminates against the parents of
Minor Plaintiffs, denying them the same ability to secure urgently-needed medical care for their
children that other parents can obtain, and does so on the basis of transgender status- and sex-based
grounds.
153. In addition to facially discriminating based on sex and transgender status, the Ban
was also passed because of its effects on transgender people, not in spite of it.
154. Discrimination based on transgender status and sex is subject to heightened scrutiny
under the Equal Protection Clause and is therefore presumptively unconstitutional, placing a
demanding burden of justification upon the State to provide at least an exceedingly persuasive
that define that class as a discrete group. These characteristics bear no relation to transgender
and across the country and remain a very small minority of the American population that lacks
political power.
157. Gender identity is a core, defining trait, that cannot be changed voluntarily or
through medical intervention, and is so fundamental to one’s identity and conscience that a person
158. The Ban does nothing to protect the health or well-being of minors. To the contrary,
it gravely threatens the health and well-being of adolescents with gender dysphoria by denying
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159. The Ban’s discriminatory treatment of healthcare for transgender adolescents is not
adequately tailored to any sufficiently important government interest, nor is it even rationally
160. The asserted justifications for the Ban make no sense in light of how other medical
161. The Ban’s targeted prohibition on medically necessary care for transgender
adolescents is based on generalized fears, negative attitudes, stereotypes, and moral disapproval
of transgender people, which are not legitimate bases for unequal treatment under any level of
scrutiny.
162. The ban violates the equal protection rights of the Minor Plaintiffs and their parents,
and the equal protection rights of Dr. Lacy’s current and future adolescent patients.
COUNT TWO
THE HEALTH CARE BAN VIOLATES THE RIGHT TO
PARENTAL AUTONOMY GUARANTEED BY THE
FOURTEENTH AMENDMENT’S DUE PROCESS CLAUSE
(PARENT PLAINTIFFS AGAINST STATE OFFICIAL DEFENDANTS)
163. Plaintiffs repeat and reallege each and every allegation contained in paragraphs 1
164. State Official Defendants are all governmental actors and/or employees acting
under color of State law for purposes of 42 U.S.C. § 1983 and the Fourteenth Amendment.
165. The Due Process Clause of the Fourteenth Amendment, enforceable pursuant to 42
U.S.C. § 1983, protects the fundamental right of parents to make decisions concerning the care,
166. That fundamental right of parents includes the right to seek and to follow medical
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167. Parents’ fundamental right to seek and follow medical advice is at its apogee when
the parents, their minor child, and that child’s doctor all agree on an appropriate course of medical
treatment.
168. The Health Care Ban’s prohibition against well-accepted medical treatments for
adolescents with gender dysphoria deprives Tennessee parents of their fundamental right to make
decisions concerning the care of their children. The Ban also discriminates against the Parent
169. The Ban does nothing to protect the health or well-being of minors. To the contrary,
it gravely threatens the health and well-being of adolescents with gender dysphoria by denying
their parents the ability to obtain necessary medical care for them.
170. The Ban’s prohibition against the provision of medically accepted treatments for
adolescents with gender dysphoria is not narrowly tailored to serve a compelling government
171. The Health Care Ban violates the fundamental rights of the parent plaintiffs.
COUNT THREE
THE HEALTH CARE BAN IS PREEMPTED BY SECTION 1557
OF THE AFFORDABLE CARE ACT
(PROVIDER PLAINTIFF AGAINST STATE OFFICIAL DEFENDANTS)
172. Plaintiffs repeat and reallege each and every allegation contained in paragraphs 1
173. Federal courts have equity jurisdiction to issue injunctive and declaratory relief
174. Under Section 1557 of the ACA, “an individual shall not, on [any] ground
prohibited under . . . Title IX of the Education Amendments of 1972 (20 U.S.C. 1681, et seq.),”—
which includes discrimination “on the basis of sex”—“be excluded from participation in, be denied
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the benefits of, or be subjected to discrimination under, any health program or activity, any part of
insurance, or under any program or activity that is administered by an Executive Agency or any
entity established under this title (or amendments).” 42 U.S.C. § 18116(a); 45 C.F.R. § 92.3.
175. Provider Plaintiff is engaged in a health program or activity, i.e., providing medical
Section 1557, including reimbursement under the federal Medicaid and Medicare programs.
177. The Health Care Ban prohibits Provider Plaintiff from performing or administering
medical procedures performed “for the purpose of . . . [e]nabling a minor to identify with” a gender
identity different from the sex they were designated at birth or “[t]reating purported discomfort or
distress from a discordance between the minor’s sex and asserted identity.” Tenn. Code Ann. § 68-
33-103(a)(1)(A)–(B).
178. The Ban thus requires Provider Plaintiff to discriminate against adolescents on the
basis of their sex. This places Provider Plaintiff in the untenable position of either violating
Section 1557 of the federal ACA by refusing to provide care to transgender adolescents or
violating the Tennessee Health Care Ban by continuing to provide care for transgender adolescents.
If the Provider Plaintiff refuses to provide care, she will be subject to civil liability for
discrimination under Section 1557; and if she provides care, she will be subject to civil liability
under the Health Care Ban. This conflict is resolved by the U.S. Constitution. The Supremacy
Clause within Article VI of the Constitution dictates that federal law is the “supreme law of the
land.”
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179. The Health Care Ban is thus preempted by the ACA, and the Provider Plaintiff is
entitled to declaratory and injunctive relief enjoining the State Official Defendants from enforcing
COUNT FOUR
THE HEALTH CARE BAN VIOLATES SECTION 1557
OF THE AFFORDABLE CARE ACT
(ALL PLAINTIFFS AGAINST DEFENDANTS TENNESSEE DEPARTMENT OF
HEALTH AND TENNESSEE BOARD OF MEDICAL EXAMINERS)
180. Plaintiffs repeat and reallege each and every allegation contained in paragraphs 1
181. Section 1557 of the ACA is enforceable through a private right of action.
182. Under Section 1557, “an individual shall not, on the ground prohibited
includes discrimination “on the basis of sex”—“be excluded from participation in, be denied the
benefits of, or be subjected to discrimination under, any health program or activity, any part of
insurance, or under any program or activity that is administered by an Executive Agency or any
entity established under this title (or amendments).” 42 U.S.C. § 18116(a); 45 C.F.R. § 92.3.
for many aspects of public health in Tennessee and provides health services to many Tennesseans
185. Defendant Medical Board is a “board . . . attached to the” DOH, Tenn. Code Ann.
§ 68-33-102(2)(B), with the power to license, regulate and discipline health care providers within
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186. Defendant DOH receives federal financial assistance, including grants, contracts,
and other financial assistance from the United States Department of Health and Human Services,
as well as federal Medicare and Medicaid funds. By virtue of its attachment to the Defendant
187. Minor Plaintiffs and their parents seek the benefits of healthcare regulated by the
188. Minor Plaintiffs will be denied those benefits and subjected to discrimination on
account of their sex because the Health Care Ban requires the DOH and agencies, boards, councils,
and committees attached to the DOH, including the Medical Board, to take emergency action
against healthcare providers who perform or administer medical procedures “for the purpose
of…[e]nabling a minor to identify with” a gender identity different from the sex they were
designated at birth or “[t]reating purported discomfort or distress from a discordance between the
189. The Health Care Ban necessarily requires the DOH and the Medical Board to
violate Section 1557 by requiring that it discriminate on the basis of sex and transgender status, to
the substantial injury of the Minor Plaintiffs who will be deprived of medical care, the Parent
Plaintiffs who are unable to obtain care for their children, and the Provider Plaintiff who is unable
to provide care.
190. The Plaintiffs are therefore entitled to declaratory and injunctive relief prohibiting
the DOH and the Medical Board from complying with the Health Care Ban.
i. Enter a judgment declaring that the Health Care Ban violates the Equal Protection
Clause; violates the fundamental rights of parents guaranteed by the Due Process
- 41 -
Clause; is preempted by Section 1557 of the Affordable Care Act; and violates Section
ii. Issue preliminary and permanent injunctions enjoining Defendants, their employees,
agents, and successors in office from enforcing the Health Care Ban;
iii. Award Plaintiffs their costs and expenses, including reasonable attorneys’ fees,
iv. Grant such other relief as the Court deems just and proper.
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Dated: April 20, 2023 Respectfully submitted,
s/ Stella Yarbrough
Stella Yarbrough, BPR No. 033637
Lucas Cameron-Vaughn, BPR No. 036284** Joseph L. Sorkin*
Jeff Preptit, BPR No. 038451** Dean L. Chapman, Jr.*
ACLU Foundation of Tennessee Kristen W. Chin*
P.O. Box 120160 Richard J. D’Amato*
Nashville, TN 37212 Akin Gump Strauss Hauer & Feld LLP
Tel.: 615-320-7142 One Bryant Park
Attorneys for the Plaintiffs New York, NY 10036
Tel.: 212-872-1000
Joshua A. Block* Attorneys for the Plaintiffs
Chase Strangio*
American Civil Liberties Union Foundation Elizabeth D. Scott*
125 Broad Street, Floor 18 Akin Gump Strauss Hauer & Feld LLP
New York, NY 10004 2300 N. Field Street, Suite 1800
Tel.: 212-549-2593 Dallas, TX 75201
Attorneys for the Plaintiffs Tel.: 214-969-2800
Attorney for the Plaintiffs
Sruti J. Swaminathan*
Lambda Legal Defense and Education Fund, Christopher J. Gessner*
Inc. David Bethea*
120 Wall Street, 19th Floor Akin Gump Strauss Hauer & Feld LLP
New York, NY 10005 Robert S. Strauss Tower
Tel.: 212-809-8585 2001 K Street N.W.
Attorney for the Plaintiffs Washington, DC 20006
Tel.: 202-887-4000
Avatara A. Smith-Carrington* Attorneys for the Plaintiffs
Lambda Legal Defense and Education Fund,
Inc.
1776 K Street N.W., 8th Floor
Washington DC 20006
Tel.: 202-804-6245
Attorney for the Plaintiffs
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