[PUBLISH] In the United States Court of Appeals For the Eleventh Circuit

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No. 22-11707 ____________________

PAUL A. EKNES-TUCKER, Rev., BRIANNA BOE, individually and on behalf of her minor son, Michael Boe, JAMES ZOE, individually and on behalf of his minor son, Zachary Zoe, MEGAN POE, individually and on behalf of her minor daughter, Allison Poe, KATHY NOE, et al., individually and on behalf of her minor son, Christopher Noe, Plaintiffs-Appellees, versus GOVERNOR, OF THE STATE OF ALABAMA, ATTORNEY GENERAL, STATE OF ALABAMA, USCA11 Case: 22-11707 Document: 125-1 Date Filed: 08/21/2023 Page: 2 of 59

2 Opinion of the Court 22-11707

DISTRICT ATTORNEY, FOR MONTGOMERY COUNTY, DISTRICT ATTORNEY, FOR CULLMAN COUNTY, DISTRICT ATTORNEY, FOR LEE COUNTY, et al.,

Defendants-Appellants.

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Appeal from the United States District Court for the Middle District of Alabama D.C. Docket No. 2:22-cv-00184-LCB-SRW ____________________

Before LAGOA, BRASHER, Circuit Judges, and BOULEE,* District Judge. LAGOA, Circuit Judge: This appeal centers around section 4(a)(1)–(3) of Alabama’s Vulnerable Child Compassion and Protection Act (the “Act”). Sec- tion 4(a)(1)–(3) of the Act states that “no person shall engage in or cause” the prescription or administration of puberty blocking med- ication or cross-sex hormone treatment to a minor “for the purpose of attempting to alter the appearance of or affirm the minor’s per- ception of his or her gender or sex, if that appearance or perception is inconsistent with the minor’s sex.” Thus, section 4(a)(1)–(3)

* Honorable J. P. Boulee, United States District Judge for the Northern District

of Georgia, sitting by designation. USCA11 Case: 22-11707 Document: 125-1 Date Filed: 08/21/2023 Page: 3 of 59

22-11707 Opinion of the Court 3

makes it a crime in the State of Alabama to take part in providing puberty blockers or cross-sex hormone treatment to a minor for purposes of treating a discordance between the minor’s biological sex and sense of gender identity. Shortly after the Act was signed into law, a group of transgender minors, their parents, and other concerned individuals challenged the Act’s constitutionality, claiming that it violates the Due Process Clause and the Equal Protection Clause of the Four- teenth Amendment. As part of that lawsuit, the district court is- sued a preliminary injunction enjoining Alabama from enforcing section 4(a)(1)–(3) of the Act pending trial, having determined that the plaintiffs are substantially likely to succeed on both of the afore- mentioned claims. Specifically, as to the due process claim, the dis- trict court held that there is a constitutional right to “treat [one’s] children with transitioning medications subject to medically ac- cepted standards” and that the restrictions of section 4(a)(1)–(3) likely impermissibly infringe upon that constitutional right. As to the equal protection claim, the district court held that section 4(a)(1)–(3) c