2:24-cv-04734-BHH Date Filed 08/29/24 Entry Number 1 Page 1 of 61

IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF SOUTH CAROLINA
Charleston Division

STERLING MISANIN, on his own behalf and on

behalf of those similarly situated; JANE DOE,
on her own behalf and on behalf of those
similarly situated; JILL RAY, on her own behalf
and on behalf of those similarly situated; NINA
NOE, by and through her parent and next
friend, Nancy Noe, on her own and on behalf Case No.: 2:24-cv-04734-BHH
of those similarly situated; NANCY NOE, on her
own and on behalf of those similarly situated; CLASS ACTION COMPLAINT FOR
GRANT GOE, by and through his parent and DECLARATORY AND INJUNCTIVE
next friend, Gary Goe, on his own and on RELIEF
behalf of those similarly situated; GARY GOE,
on his own and on behalf of those similarly
situated;
Plaintiffs,
v.

ALAN WILSON, in his official capacity as

Attorney General of South Carolina; SOUTH
CAROLINA DEPARTMENT OF HEALTH AND
HUMAN SERVICES (DHHS); ROBERT KERR, in
his official capacity as Director of DHHS;
SOUTH CAROLINA PUBLIC EMPLOYEE BENEFIT
AUTHORITY (PEBA); PEGGY BOYKIN, in her
official capacity as Executive Director of
South Carolina PEBA; MEDICAL UNIVERSITY
OF SOUTH CAROLINA (MUSC); JAMES LEMON;
GUY CASTLES III; DONALD R. JOHNSON II;
RICHARD M. CHRISTIAN, JR.; HENRY
FREDERICK BUTEHORN III; G. MURRELL
SMITH, SR.; W. MELVIN BROWN III; PAUL T.
DAVIS; MICHAEL E. STAVRINAKIS; WILLIAM H.
BINGHAM, SR.; CHARLES W. SCHULZE;
THOMAS L. STEPHENSON; TERRI R. BARNES;
BARBARA JOHNSON-WILLIAMS; THE
HONORABLE JAMES A. BATTLE, JR.; BARTLETT
J. WITHERSPOON, JR., each in their official
capacities as board members of MUSC; DAVID
COLE, in his official capacity as President of
MUSC;

Defendants.
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Plaintiffs, 1 by and through their attorneys, bring this Complaint against the above-named

Defendants, and state the following in support thereof:

INTRODUCTION

1. On May 21, 2024, Governor Henry D. McMaster of South Carolina signed into law

House Bill 4624 (“H 4624”). H 4624 broadly prohibits healthcare professionals from providing

medically necessary and potentially lifesaving gender-affirming healthcare to transgender

adolescents, even though these treatments are available to cisgender adolescents. H 4624 also

prohibits public funds from being used to fund any gender-affirming care, regardless of the age of

the patient, and prevents Medicaid from reimbursing or providing coverage, depriving transgender

people across South Carolina of necessary medical care.

2. H 4624 flies in the face of widely accepted professional standards of medical care

for transgender people, rejects the opposition of medical experts and healthcare providers to

government-imposed bans on treatment, and ignores the pleas of South Carolina families who

urged lawmakers not to interfere with the medical decision-making of individuals, their families,

and their doctors.

1
As set forth in the concurrently-filed motion to proceed pseudonymously, Plaintiffs Jane Doe and
Jill Ray seek to proceed pseudonymously in order to protect their right to privacy given that
disclosure of their identities “would reveal matters of a highly sensitive and personal nature,
specifically [their] transgender status and [their] diagnosed medical condition—gender
dysphoria.” Foster v. Andersen, No. 182552-DDC-KGG, 2019 WL 329548, at *2 (D. Kan. Jan.
25, 2019); see also Hersom v. Crouch, 2:21-CV-00450, 2022 WL 908503, at *2 (S.D.W. Va. Mar.
28, 2022) (allowing a plaintiff to proceed pseudonymously because of the stigma associated with
their transgender identity). Plaintiffs Nina Noe and her parent and next friend, Nancy Noe, and
Grant Goe and his parent and next friend, Gary Goe, seek to proceed pseudonymously in order to
protect their right to privacy for the same reasons that apply to Doe and Ray as transgender people
and also because Nina Noe and Grant Goe are minors.

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3. Medical providers have long followed evidence-based and comprehensive clinical

practice guidelines that recommend certain medical treatments for gender dysphoria—a serious

medical condition characterized by clinically significant distress caused by incongruence between

a person’s gender identity and their sex designated at birth. These guidelines—including those

promulgated by the World Professional Association for Transgender Health (“WPATH”) and the

Endocrine Society—provide a framework for the safe and effective treatment of gender dysphoria,

which, if left untreated, can have dire consequences for the health and wellbeing of transgender

people, including adolescents.

4. All the major medical associations in the United States—including the American

Medical Association, the American Academy of Pediatrics, the American Academy of Child &

Adolescent Psychiatry, among many others—recognize these medical guidelines as authoritative

and further recognize that adolescents with gender dysphoria may require medical interventions to

treat clinically significant distress associated with their condition.

5. H 4624 seeks to deny or impede access to “gender transition procedures,” defined

to include many of the exact treatments recommended by these well-established medical

guidelines. In particular, H 4624 (1) categorically prohibits medical professionals from providing

“gender transition procedures” to individuals under the age of 18, S.C. Code Ann. § 44-42-320

(the “Healthcare Ban” or the “Ban”); (2) prohibits “public funds” from being used “directly or

indirectly for gender transition procedures,” regardless of age, S.C. Code Ann. § 44-42-340 (the

“Public Funds Restriction”); and (3) excludes “gender transition procedures” from coverage under

the South Carolina Medicaid Program, again regardless of age, S.C. Code Ann. § 44-42-35 (the

“Medicaid Restriction”).

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6. While H 4624’s sponsors contend that gender-affirming care is “experimental,”

decades of clinical experience and research demonstrate otherwise: gender-affirming health care

is safe and effective, and it improves the health and well-being of adolescents (and adults) with

gender dysphoria.

7. Moreover, and critically, the three challenged provisions of H 4624—the

Healthcare Ban, the Public Funds Restriction, and the Medicaid Restriction—do not seek to

broadly prohibit the medical treatments at issue for all purposes; rather they prohibit the provision

of these treatments only when they are performed for the purpose of “gender transition.” In other

words, the law permits many of the medical interventions denied to transgender individuals

seeking treatment for gender dysphoria if used to treat cisgender individuals; for example, to treat

precocious puberty, prostate cancer, breast cancer, or endometriosis. Likewise, the law permits

surgical interventions, such as breast augmentation or reconstruction, to be covered by Medicaid

or paid for (indirectly or directly) by public funds for cisgender people, but not for transgender

people seeking treatment for gender dysphoria (even when medically necessary). This distinction

reveals that the purpose of H 4624 is not to regulate harmful medical practices or protect the public

but to deny transgender people seeking treatment for gender dysphoria—and only transgender

people seeking treatment for gender dysphoria—access to medical care permitted for non-

transgender people.

8. H 4624 has had and will continue to have devastating consequences for transgender

individuals and their families in South Carolina. Transgender people diagnosed with gender

dysphoria will be unable to obtain the medical care that those who understand their diagnosis—

their doctors and, in the case of transgender youth, also their parents—agree they need. Untreated

gender dysphoria is associated with severe harm, including anxiety, depression, and suicidality.

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Cutting off vulnerable individuals from treatment or withholding necessary care will inevitably

and directly cause significant harm.

9. Indeed, in the face of H 4624, some parents of transgender adolescents are making

plans to uproot their lives and their families by fleeing the State in order 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

shoulder the hardship of disruptive and expensive travel to secure medical care for their children

out of state, often at the expense of the adolescent’s time in school and the parents’ time at work.

10. Other individuals and families that do not have the resources or are otherwise

unable to leave or travel are terrified about what will happen if the law continues to remain in

effect. For these families and hundreds of others across South Carolina, H 4624 has created a sense

of desperation at the prospect of watching their loved one’s suffering resume and symptoms

possibly worsen as they are unable to access the medical care that they need.

11. H 4624 not only gravely threatens the health and wellbeing of transgender

adolescents and adults in South Carolina; it is unconstitutional and violates federal statutory

prohibitions on discrimination based on sex and disability. H 4624 violates the Equal Protection

Clause of the Fourteenth Amendment because it draws distinctions based on sex and transgender

status and lacks an exceedingly persuasive justification. See Kadel v. Folwell, 100 F.4th 122 (4th

Cir. 2024) (en banc). H 4624 additionally violates the Due Process Clause of the Fourteenth

Amendment because it curtails the fundamental rights of parents to make decisions concerning the

care of their children. The law’s sex-based discrimination also violates the Medicaid Act and the

Affordable Care Act, and, by singling out people with gender dysphoria for discrimination, H 4624

also violates the Americans with Disabilities Act (“ADA”) and the Rehabilitation Act.

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12. Given the grave harms imposed by the Healthcare Ban, the Public Funds

Restriction, and the Medicaid Restriction, Plaintiffs urgently seek relief from this Court.

PARTIES

I. Plaintiffs

A. Minor Plaintiffs and Their Families

13. Plaintiffs Nina Noe and Nancy Noe live in South Carolina. Nancy Noe is the

mother of Nina Noe, her 15-year-old daughter. Nina Noe is transgender. She knew from a young

age that her gender identity did not match her sex assigned at birth. Nina, who has been diagnosed

with gender dysphoria, has been prescribed and had previously been receiving medically necessary

care that is currently prohibited by the Healthcare Ban. She will no longer have access to this care

once the statutory “taper-off” period ends on January 31, 2025. Furthermore, until the Medicaid

Restriction went into effect, Nina had insurance coverage for her treatment through Medicaid. Due

to the Medicaid Restriction, Nancy and her family will have to pay-out-pocket for any care Nina

is able to secure outside of South Carolina.

14. Plaintiffs Grant Goe and Gary Goe live in South Carolina. Gary is the father of

Grant, his seventeen-year-old son. Grant is transgender. Grant knew from a very young age that

his gender identity did not match his sex assigned at birth. Grant, who has been diagnosed with

gender dysphoria, has been prescribed and had previously been receiving medically necessary care

that is currently prohibited by the Healthcare Ban. He will no longer have access to this care once

the statutory “taper-off” period ends on January 31, 2025.

B. Adult Plaintiffs

15. Plaintiff Sterling Misanin is a 32-year-old transgender man living in Charleston,

South Carolina. Misanin, who has been diagnosed with gender dysphoria, receives primary care

through the Medical University of South Carolina (“MUSC”). At the recommendation of his

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healthcare providers, Misanin planned to have gender-affirming surgery at a MUSC Health facility

this year. After obtaining pre-authorization from his private insurer, and scheduling the procedure,

MUSC denied Misanin treatment and stated, “due to the enactment of recent SC legislation

H 4624, MUSC Health cannot offer patients gender transition procedures.” At personal expense,

Misanin was forced to delay his treatment in order to obtain additional pre-authorization for a

procedure at a different facility, where he will not have continuity of care with his primary care

provider.

16. Plaintiff Jill Ray is a 36-year-old transgender woman living in Richland County,

South Carolina. Ray, who has been diagnosed with gender dysphoria, is enrolled in and receives

health care coverage through the South Carolina Public Employee Benefit Authority (“PEBA”)

and Veterans Affairs (“VA”) Health Care. At the recommendation of her health care providers,

Ray plans to have gender-affirming surgery, which was covered by PEBA until the passage of

H 4624. Ray received referrals and had even selected a specific doctor to perform her surgery. Ray

has been enrolled in PEBA at all times relevant to this complaint.

17. Plaintiff Jane Doe is a 32-year-old transgender woman and physician living in

Charleston, South Carolina. Doe, who has been diagnosed with gender dysphoria and is enrolled

in and receives health care coverage through PEBA. Doe started hormone therapy in 2021 and has

scheduled surgery for November 11, 2024. Doe’s gender-affirming medical care had always been

covered by her PEBA insurance, until the passage of H 4624. Doe has now been informed by her

health plan administrators because the state health plan is required to adhere to state law, including

H 4624, her insurance will not cover the cost of her surgical care; without insurance coverage, she

cannot proceed with her scheduled surgery. Doe has been enrolled in PEBA at all times relevant

to this complaint.

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II. Defendants

18. Defendant Alan Wilson is the Attorney General of South Carolina. The Attorney

General is headquartered at 1000 Assembly Street, Room 519, Columbia, SC 29201. Under

H 4642, Defendant Wilson in his capacity as Attorney General is responsible for enforcing South

Carolina’s prohibitions on gender transition procedures. S.C. Code Ann. § 44-42-360(F).

Defendant Wilson is sued in his official capacity.

19. Defendant South Carolina Department of Health and Human Services

(“DHHS”) is the “single state agency” charged with administering the Medicaid program in South

Carolina (“SC Medicaid”). 42 U.S.C. § 1396a(a)(5); S.C. Code Ann. § 44-6-30 (2024).

20. Defendant DHHS 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”).

21. Defendant DHHS is a recipient of federal financial assistance, such as grants,

contracts, and other financial assistance from the United States Department of Health and Human

Services, as well as federal Medicare and Medicaid funds.

22. DHHS must abide by the anti-discrimination mandates that follow those funds and

is a covered entity that is subject to the anti-discrimination mandate of Section 1557 of the

Affordable Care Act. 42 U.S.C. § 18116; 45 C.F.R. § 92.4.

23. DHHS is also a “public entity” as defined by the ADA.

24. Upon information and belief, Defendant DHHS was at all relevant times a recipient

of federal financial assistance and, therefore, subject to the Rehabilitation Act.

25. SC Medicaid supports the health and wellbeing of more than one million South

Carolinians—nearly one in five people across the state—by providing critical health insurance

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coverage for individuals and families with low incomes, as well as medically fragile children,

children adopted through foster care, and people with severe disabilities.

26. DHHS is a recipient of federal financial assistance. DHHS receives federal funding

to support the SC Medicaid Program and uses the funds it receives from the federal government

in part to cover healthcare services for persons enrolled in the SC Medicaid Program. The state,

through DHHS, is responsible for the nonfederal share of the costs of medical services provided

under the Program.

27. Defendant Robert Kerr is the Director and head of DHHS. S.C. Code Ann. § 44-

6-10 (2024). In this capacity, Defendant Kerr oversees and directs all functions at DHHS, including

its Medicaid operations. S.C. Code Ann. § 44-6-100. Defendant Kerr is sued in his official

capacity.

28. Defendant South Carolina Public Employee Benefit Authority manages the

health plans of over 530,000 South Carolinian state employees and their dependents.

29. PEBA receives both state and federal funds, including $71 million in ARPA funds

and over $210 million in Medicare Part D subsidies in fiscal year 2023.

30. PEBA is a “health program or activity” within the meaning of Section 1557.

31. PEBA must abide by the anti-discrimination mandates that follow those funds and

is a covered entity that is subject to the anti-discrimination mandate of Section 1557 of the

Affordable Care Act. 42 U.S.C. § 18116; 45 C.F.R. § 92.4.

32. PEBA is also a “public entity” as defined by the ADA.

33. Upon information and belief, Defendant PEBA was at all relevant times a recipient

of federal financial assistance and, therefore, subject to the Rehabilitation Act.

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34. Defendant Peggy Boykin is the Executive Director of the South Carolina PEBA.

Defendant Boykin is “charged with the affirmative duty to carry out the mission, policies, and

direction” of PEBA. S.C. Code Ann. § 9-4-10(J). State law anticipates suits in equity against

Defendant Boykin in her official capacity. See S.C. Code Ann. § 9-4-15 (“The State shall defend

officers and management employees of PEBA against a claim or suit that arises out of or by virtue

of performance of official duties.”).

35. Defendant Medical University of South Carolina operates medical facilities,

known as MUSC Health.

36. MUSC receives both state and federal funds. E.g. S.C. Code Ann. § 59-123-60.

37. In Fiscal Year 2024, MUSC will receive more than $121 million in state funds.

38. MUSC is a “health program or activity” within the meaning of Section 1557.

39. MUSC must abide by the anti-discrimination mandates that follow those funds and

is a covered entity that is subject to the anti-discrimination mandate of Section 1557 of the

Affordable Care Act. 42 U.S.C. § 18116; 45 C.F.R. § 92.4.

40. MUSC is also a “public entity” as defined by the ADA.

41. Upon information and belief, Defendant MUSC was at all relevant times a recipient

of federal financial assistance and, therefore, subject to the Rehabilitation Act.

42. The Board of Trustees of the Medical University of South Carolina (the “Board”)

is the governing body of the Medical University of South Carolina. S.C. Code Ann. § 59-123-40.

In that capacity, the Board is vested with the management and control of MUSC, including MUSC

Health and the insurance plan offered to MUSC employees and dependents, the MUSC Health

Plan.

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43. Defendant James Lemon, D.M.D., is the Chairman of the Board. Defendant C.

Guy Castles III, M.D. is a member of the Board and serves as the designee of the Governor. S.C.

Code Ann. § 59-123-40. Defendants Donald R. Johnson II, M.D., Richard M. Christian, Jr.,

M.D., Henry Frederick Butehorn III, M.D., G. Murrell Smith, Sr., M.D., W. Melvin Brown

III, M.D., Paul T. Davis, D.M.D., Michael E. Stavrinakis, B.S., William H. Bingham, Sr.,

P.E., Charles W. Schulze, C.P.A., Thomas L. Stephenson, Esq., Terri R. Barnes, B.S.,

Barbara Johnson-Williams, Ed.S., The Honorable James A. Battle, Jr., M.B.A., and Bartlett

J. Witherspoon, Jr., M.D. (collectively and together with Defendants Lemon and Castles, the

“MUSC Board Defendants”) are members of the Board. The Medical Board Defendants are sued

in their official capacities.

44. Defendant David J. Cole, M.D., FACS is the president of MUSC. Defendant Cole

is sued in his official capacity.

45. Defendants Wilson, Kerr, Boykin, and Cole and the MUSC Board 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.

JURISDICTION AND VENUE

46. This action arises under the U.S. Constitution, 42 U.S.C. § 1983, 42 U.S.C.

§ 18116(a), 42 U.S.C. § 1396a(a), 42 U.S.C. § 12101 (2009) et seq., and 29 U.S.C. § 794 (2016).

47. This Court has subject matter jurisdiction pursuant to Article III of the United States

Constitution and 28 U.S.C. §§ 1331, 1343.

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48. Venue is proper pursuant to 28 U.S.C. § 1391(b) because a substantial part of the

events or omissions giving rise to the claims brought by Plaintiff have occurred in the District of

South Carolina and the Defendants are located in the District.

49. Venue is proper in the Charleston division under Local Civil Rule 3.01 because that

is where several Plaintiffs and Defendants reside and where a substantial portion of the events or

omissions giving rise to the claims occurred.

FACTUAL ALLEGATIONS

III. Gender-Affirming Care is the Standard Treatment for Gender Dysphoria

A. Gender Identity and Gender Dysphoria

50. The term “gender identity” refers to an individual’s innate, deeply felt sense of their

own belonging to a particular gender, including male and female. 2 Every person has a gender

identity.

51. Gender identity has a strong biological basis. Researchers agree that external efforts

to change a person’s gender identity are unsuccessful and unethical. 3

52. In the majority of cases, a person’s gender identity is congruous with the sex

assigned to them by a physician or parent at birth. “Sex assigned at birth” or “sex designated at

birth” refers to the sex marker given to an infant at birth based on external physiological

characteristics. 4

2
WPATH, Standards of Care for the Health of Transgender and Gender Diverse People, Version
8 (“SOC 8”), Appendix B (Glossary).
3
AMA Issue Brief, Sexual orientation and gender identity change efforts (so-called “conversion
therapy”), available at https://www.ama-assn.org/system/files/conversion-therapy-issue-brief.pdf.
4
Wylie C. Hembree et al., Endocrine Treatment of Gender-Dysphoric/GenderIncongruent
Persons: An Endocrine Society Clinical Practice Guideline, 102 J. Clinical Endocrinology and
Metabolism 3869, 3875 tbl. 1 (2017), available at

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53. Though H 4624 uses the term “biological indication” (e.g., § 44-42-310), “sex

assigned at birth” or “sex designated at birth” are more precise terminology than “biological

indication” because the physiological aspects of a person’s sex are not always in alignment with

one another or with the person’s chromosomal configuration. For example, some intersex persons

may have a chromosomal configuration typically associated with persons assigned male at birth,

but genital characteristics associated with persons assigned female at birth. The Endocrine Society,

an international medical organization representing over 18,000 endocrinology researchers and

clinicians, warns practitioners that the terms “biological sex” and “biological male or female” are

imprecise and should be avoided. 5

54. Transgender people are those whose gender identity is different from their sex

assigned at birth. A transgender boy or man is someone who has a male gender identity but was

designated female at birth. A transgender girl or woman has a female gender identity but was

designated male at birth. A nonbinary person is someone whose gender identity does not clearly

align with either male or female identity, and many nonbinary people identify themselves as

transgender because their gender identity does not align with their sex assigned at birth. 6

55. Mental health professionals have consistently observed that people are happier

when they are able to live in a manner consistent with their gender identity. For most people, this

is not difficult because their sex assigned at birth is in alignment with their gender identity. These

people are sometimes referred to as “cisgender.” For transgender individuals, however, the

incongruence between sex assigned at birth and gender identity can create distress.

https://academic.oup.com/jcem/article/102/11/3869/4157558 (“Endocrine Society Guideline”);

SOC 8 at S76.
5
Endocrine Society Guideline at 3875 tbl. 1.
6
SOC 8, Appendix B (Glossary).
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56. When this incongruence creates clinically significant distress, clinicians diagnose

the distress as “gender dysphoria.” WPATH defines “gender dysphoria” as “a state of distress or

discomfort that may be experienced because a person’s gender identity differs from that which is

physically and/or socially attributed to their sex assigned at birth.” 7

57. Gender dysphoria is a serious medical condition included in the American

Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorder, Fifth Edition,

Text Revision (“DSM-5-TR”) (2022).

B. Standards of Gender-Affirming Medical Care

58. To treat gender dysphoria, doctors in South Carolina and across the United States

apply evidence-based, well-researched standards of care. These standards are based on decades of

clinical experience and published, peer-reviewed research. These standards recommend an

individualized plan for treatment that focuses on helping a person live in accordance with their

gender identity and feel at home in their body. Generally, this methodology is referred to as

“gender-affirming” or “transition-related” medical care, and it is the only evidence-based

treatment for gender dysphoria. There is consensus in the medical community that without access

to this care, individuals who suffer from gender dysphoria are worse off. Gender-affirming medical

care may include a range of treatments, including counseling, medication, and, in some cases,

surgical interventions and procedures, that are tailored to each individual’s experience with the

condition and their transition.

59. Gender-affirming care seeks to alleviate or eliminate feelings of gender dysphoria

by helping a transgender person live in alignment with their gender identity, specifically by

7
SOC 8, Appendix B (Glossary).
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prescribing treatment and procedures which will bring the sex-specific characteristics of a

transgender person’s body into alignment with their identity.

60. Gender-affirming care may be recommended for all patients who experience gender

dysphoria, including both adults and minors. 8 The standards of gender-affirming care for minors

(including children 9 and adolescents 10) vary by age: for example, no medical treatments are

available or recommended for those who have not yet started puberty. 11 But medical professionals

agree that adolescents experiencing gender dysphoria nevertheless require the same individualized

approach as adults to create a successful treatment plan.

61. The treatment of gender dysphoria with gender-affirming medical care is not new—

medical and mental health professionals have long provided assistance to transgender people to

live in accordance with their gender identity, including by providing gender-affirming medical

care.

62. WPATH, an “interdisciplinary professional and educational organization devoted

to transgender health,” 12 has issued published versions of standards of gender-affirming care since

1979. The most recent version, published in 2022, is Standards of Care for the Health of

Transgender and Gender Diverse People, Version 8 (“SOC 8”).

8
“Minor” is used to refer to anyone under eighteen years of age, as it is used in the law at issue,
S.C. Code Ann. § 44-42-310 et seq., and as it is used in the WPATH Standards of Care, SOC 8 at
S44; S62.
9
“Child,” “children” and “childhood” are used to describe persons below the legal age of majority
who have not yet started puberty (prepubescent). SOC 8 at S67.
10
“Adolescent,” “adolescents,” and “adolescence” are used to describe persons below the legal
age of majority who have begun puberty. SOC 8 at S44.
11
SOC 8 at S110, S128 (listing only adolescents and adults as potential surgery recipients).
12
WPATH, Mission & Vision, https://wpath.org/about/mission-and-vision.
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63. SOC 8’s recommendations are based on a rigorous and methodological evidence-

based review of existing data and clinical experience.

64. The Endocrine Society, a professional society representing those in the field of

adult and pediatric endocrinology, has a set of clinical practice guidelines for the provision of

hormone therapy as a treatment for gender dysphoria in minors and adults (the “Endocrine Society

Guideline”). 13

65. SOC 8 and the Endocrine Society Guideline are widely accepted in the medical

community. The American Medical Association, the American Academy of Pediatrics, the

American Association of Child and Adolescent Psychiatrists, the Pediatric Endocrine Society, the

American Psychiatric Association, the American Psychological Association, and other

professional medical organizations follow the WPATH and Endocrine Society standards of care

and clinical practice guidelines, which are comparable to guidelines that those professional

medical organizations use to treat other conditions.

66. Gender-affirming medical care is multidisciplinary: it may include hormones or

medication, surgical procedures, voice therapy, hair removal, reproductive care, and counseling

and mental health therapy. 14

67. Some transgender patients are prescribed hormone therapy which allows for the

patients’ physical development to match their gender identity, including by the development of

secondary sex-characteristics (sex-specific characteristics not associated with internal or external

13
See Hembree, Wylie C, et al. “Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent
Persons: An Endocrine Society Clinical Practice Guideline.” The Journal of Clinical
Endocrinology & Metabolism, vol. 102, no. 11, 2017, pp. 3869-3903.,
https://doi.org/10.1210/jc.2017-01658.
14
SOC 8 at S5.
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genitalia). Typically, hormone therapy consists of testosterone for transgender boys and men, and

estrogen and testosterone-suppression for transgender girls and women.

68. Hormone therapy allows transgender individuals to align their secondary sex-

characteristics and gender identity, thereby alleviating feelings of gender dysphoria. For this

reason, hormone therapy is considered medically necessary for some transgender people.

69. Surgical procedures are also an important component of gender-affirming care for

many transgender patients. Gender-affirming surgical procedures can be employed to align both

secondary and primary sex characteristics with a person’s gender identity. These surgeries are not

typically performed in adolescence.

70. For example, gender-affirming chest and breast surgeries, including subcutaneous

mastectomy and breast augmentation, may help a transgender person alleviate feelings of gender

dysphoria related to their torso. Facial feminization, facial masculinization, and hair removal may

help a transgender person alleviate feelings of gender dysphoria related to their face.

71. Other surgical procedures are intended to alter genitalia or primary sex

characteristics, including phalloplasty, metoidioplasty, vaginoplasty and vulvoplasty, as well as

orchiectomy and hysterectomy. 15 Each of these procedures may be medically necessary to alleviate

symptoms of gender dysphoria.

72. Treatment for gender dysphoria may include other disciplines including voice and

communication therapy; 16 sexual and reproductive healthcare; 17 and mental health care to address

15
See SOC 8, Appendix E, for a complete list of gender-affirming surgical procedures.
16
SOC 8 at S137. Endocrine Society Guideline at 3893.
17
SOC 8 at S156.
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distress, anxiety and other psychiatric symptoms, including those presenting as a result of stigma,

discrimination, and trauma. 18

C. Additional Standards for Children and Adolescents

73. In recognition of the “unique aspects that distinguish adolescence from other

developmental stages,” 19 including an emerging sense of identity, the onset of puberty, and the

importance of parental or caregiver involvement, clinical guidelines for treatment of gender

dysphoria include recommendations specific to minor patients, both children and adolescents.

74. For children experiencing gender dysphoria before the onset of puberty, under SOC

8 and the Endocrine Society Guideline, no medical interventions are indicated.

75. As minor patients enter adolescence and particularly the early stages of puberty,

medical interventions are sometimes necessary to ensure gender dysphoria is appropriately

managed. For adolescent patients, SOC 8 and the Endocrine Society Guideline recommend an

individualized approach to patients’ needs. This may include puberty-delaying treatment, hormone

therapy, and—much less frequently—limited surgical procedures for older adolescents. 20

76. SOC 8 first recommends that providers “undertake a comprehensive

biopsychosocial assessment of the adolescent” prior to initiating any medical treatment, and “that

this be accomplished in a collaborative and supportive manner.” 21

77. Adolescent patients are only eligible for medical treatment under the guidelines

upon reaching the “Tanner stage 2” of puberty. “Tanner staging refers to five stages of pubertal

18
SOC 8 at S171.
19
SOC 8 at S49.
20
SOC 8 at S50-51.
21
Id.
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development ranging from prepubertal (stage 1) to post-pubertal and adult sexual maturity (stage

5). [Tanner stage 2] is defined by the occurrence of breast budding [or] ... the achievement of a

testicular volume of greater than or equal to 4ml.” 22

78. Typically, medical treatment for adolescents beginning at early puberty (Tanner

stage 2) will first consist of puberty-delaying medications (also known as “puberty-blockers”).

This medication pauses puberty at the stage it is at when treatment begins and allows transgender

adolescents and their family time to understand their gender identity and to work with their medical

and mental health providers to develop a course of treatment that suits their individual needs.

79. For transgender girls assigned the male sex at birth, who would otherwise undergo

male puberty, puberty-delaying treatments pause the development of secondary sex characteristics

like facial hair and an “Adam’s apple.” For transgender boys assigned the female sex at birth, who

would otherwise undergo female puberty, puberty-delaying treatments pause the development of

breasts and menstruation. In addition to pausing what may be discomforting developments for

those experiencing gender dysphoria, using puberty-delaying treatment may reduce the need for

later surgical interventions.

80. Puberty-delaying treatment has been shown to be effective at treating gender

dysphoria.

81. Puberty-delaying treatment is safe.

82. Puberty-delaying treatment prevents the onset of physical changes to the body

which would worsen gender dysphoria for many people and can be necessary to effectively treat

gender dysphoria in transgender adolescents.

22
SOC 8 at S64.
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83. Puberty-delaying treatment does not permanently affect fertility on its own, though

adolescents wishing to begin using puberty-delaying treatment are first counseled about the effect

later hormone therapy (separate from puberty-delaying treatment) may have on fertility.

84. Puberty-delaying treatment is reversible. If a patient discontinues puberty-delaying

treatment, endogenous puberty resumes.

85. Even considering the reversible nature and well-documented safety of these

medications, both the Endocrine Society Guideline and SOC 8 have robust criteria for ensuring

that puberty-delaying treatment is appropriate for individual adolescents experiencing gender

dysphoria.

86. The Endocrine Society Guideline dictates that transgender adolescents who have

reached the onset of puberty may be eligible for puberty-delaying treatment, if:

(1) A qualified MHP [mental health professional] has confirmed

that: (a) the adolescent has demonstrated a long-lasting and intense
pattern of gender nonconformity or gender dysphoria (whether
suppressed or expressed), (b) gender dysphoria worsened with the
onset of puberty, (c) any coexisting psychological, medical, or social
problems that could interfere with treatment (e.g., that may
compromise treatment adherence) have been addressed, such that
the adolescent’s situation and functioning are stable enough to start
treatment, (d) the adolescent has sufficient mental capacity to give
informed consent to this (reversible) treatment,

(2) And the adolescent: (a) 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, (b) has given informed consent and
(particularly when the adolescent has not reached the age of legal
medical consent, depending on applicable legislation) the parents or
other caretakers or guardians have consented to the treatment and
are involved in supporting the adolescent throughout the treatment
process,

(3) And a pediatric endocrinologist or other clinician experienced in

pubertal assessment (a) agrees with the indication for [puberty
blocker] treatment, (b) has confirmed that puberty has started in the

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adolescent (Tanner stage ≥ G2/B2), (c) has confirmed that there are
no medical contraindications to [puberty blocker] treatment. 23

87. SOC 8 similarly provides that medical providers should provide puberty-delaying

treatment or other gender-affirming medical treatment and procedures for adolescents who have

reached the onset of puberty (Tanner stage 2), only if:

a. The adolescent meets necessary diagnostic criteria for

gender dysphoria or incongruence;

b. the experience of gender dysphoria or incongruence is

marked and sustained;

c. the adolescent demonstrates the emotional and cognitive

maturity required to provide informed consent to the
treatment;

d. the adolescent’s mental health concerns that may interfere

with diagnostic clarity, capacity to consent, or medical
treatment have been addressed; and

e. the adolescent has been informed of side-effects including

reproductive effects, and has been made aware of options to
preserve fertility. 24

88. Providers may also prescribe hormone therapy for adolescents who have begun

puberty. Adolescents may receive hormone therapy after pausing their endogenous puberty using

puberty-delaying treatment. For adolescents who seek treatment later in puberty, they may not be

eligible for pubertal suppression and may instead be treated only with hormone therapy.

89. Because hormone therapy may affect fertility, adolescents are required to first

receive counseling on those effects and on options to preserve reproductive capacity through other

means. Hormone therapy does not necessarily cause the end of reproductive capacity, and many

people treated with hormone therapy can go on to conceive and give birth to children.

23
Endocrine Society Guideline at 3878 tbl. 5.
24
SOC 8 at S57-S64 (Statements 6.12a-f).
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90. Additionally, under both SOC 8 and the Endocrine Society Guideline, all the

requirements to begin puberty-delaying treatment are necessary to begin treatment with hormone

therapy.

91. As with adults, hormone therapy consists of testosterone for transgender boys, and

estrogen and testosterone suppression for transgender girls.

92. Gender-affirming hormone therapy is also safe and effective at treating dysphoria

in adolescents, alleviating symptoms through the development of secondary sex characteristics

aligned with the adolescent’s gender identity.

93. When provided under appropriate clinical supervision, the risks and side effects of

gender-affirming hormone therapy in adolescents are rare and manageable.

94. Finally, some older adolescents may, in some cases, receive recommendations for

surgical intervention, most typically chest masculinization, before the age of 18. However, SOC 8

recommends that such treatment take place only after an adolescent has had at least 12 months of

previous hormone therapy.

IV. Treatments Used for Gender Dysphoria Are Also Used for Other Medical Conditions

95. In addition to being a common part of treatment for adolescents diagnosed with

gender dysphoria, puberty-delaying medication is commonly used to treat central 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.

96. Likewise, hormone therapy can be prescribed for adolescents for conditions other

than gender dysphoria. 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,
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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 insufficiency

(premature impairment of ovaries’ typical function including hormone and egg production),

hypogonadotropic hypogonadism (delayed puberty due to lack of estrogen caused by a problem

with the pituitary gland or hypothalamus), or Turner’s Syndrome (a chromosomal 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 and

estrogen.

97. The side effects of these treatments are comparable when used to treat gender

dysphoria and when used to treat other conditions. The use of these treatments for gender dysphoria

is not any riskier than for other conditions and diagnoses for which the same medical and surgical

treatments are regularly used. 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 must consent to treatment, and the patient must give their assent.

Treatment cannot be administered without agreement from doctors, parents, and the transgender

adolescent.

98. Furthermore, the level of evidence supporting these treatments’ efficacy is similar

to the level of evidence supporting other widely accepted pediatric medical treatments. The

evidence supporting efficacy of gender-affirming medical care for adolescents includes cross-

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sectional and longitudinal studies as well as years of clinical experience. This is comparable to the

base level of evidence supporting much of pediatric medical care.

V. South Carolina’s H 4624

A. Text of the Law

99. On May 9, 2024, the South Carolina General Assembly passed H 4624. The law

went into effect on May 21, 2024, after it was signed by Governor McMaster.

100. H 4624 makes it unlawful for health care professionals to “knowingly provide” or

“engage in the provision or performance of gender transition procedures to a person under eighteen

years of age.” S.C. Code Ann. § 44-42-320(A)-(B). It also prohibits the use of public funds

“directly or indirectly for gender transition procedures” and prohibits South Carolina’s Medicaid

Program from “reimburs[ing] or provid[ing] coverage for” gender transition procedures for all

people, including adults. S.C. Code Ann. §§ 44-42-340; 44-42-350.

101. H 4624 defines “gender transition procedures” as “puberty-blocking drugs, cross-

sex hormones, or genital or non-genital gender reassignment surgery, provided or performed for

the purpose of assisting an individual with a physical gender transition.” S.C. Code Ann. § 44-42-

310(6). The law defines “gender transition” as “the process in which a person goes from identifying

with and living as a gender that corresponds to his or her sex to identifying with and living as a

gender different from his or her sex, [which] may involve social, legal, or physical changes.” S.C.

Code Ann. § 44-42-310(5). It further defines “sex” as “the biological indication of male and female

in the context of reproductive potential or capacity, such as sex chromosomes, naturally occurring

sex hormones, gonads, and nonambiguous internal and external genitalia present at birth, without

regard to an individual’s psychological, chosen, or subjective experience of gender.” S.C. Code

Ann. § 44-42-310(1).

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102. H 4624 provides for a limited period to reduce existing treatment for adolescents.

If (1) “prior to August 1, 2024, a health care professional initiated a course of treatment that

includes the prescription, delivery, or administration of a puberty-blocking drug or a cross-sex

hormone to a person under the age of eighteen,” and (2) “the health care professional determines

and documents in the person’s medical record that immediately terminating the person’s use of the

drug or hormone would cause harm to the person,” “the health care professional may institute a

period during which the person’s use of the drug or hormone is systematically reduced.” That

period may not extend beyond January 31, 2025. S.C. Code Ann. § 44-42-320(C).

103. H 4624 prohibits medical professionals from initiating a new course of treatment

for a minor that includes the administration of puberty-blocking or cross-sex hormones for the

purpose of gender transition or a surgical gender transition procedure, and from providing that care

to existing patients after January 31, 2025.

104. H 4624 exempts the otherwise prohibited care—puberty-blocking drugs, cross-sex

hormones, and genital or non-genital gender reassignment surgery—for purposes other than

providing gender-affirming care. It exempts the following:

a. “care for persons being treated for “precocious puberty,

prostate cancer, breast cancer, endometriosis, or other
procedure unrelated to gender transition, or to a person who
was born with a medically verifiable disorder of sexual
development including, but not limited to, a person with
external biological sexual characteristics that are ambiguous
including, but not limited to, people who were born with
forty-six XX chromosomes with virilization or forty-six XY
chromosomes with under virilization or having both ovarian
and testicular tissue”;

b. “appropriate medical services to treat a disorder of sexual

development arising because the person does not have
normal sex chromosome structure, sex steroid hormone
production, or sex steroid hormone action that was
diagnosed through genetic or biochemical testing”;

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c. “treatment of any infection, injury, disease, or disorder that

has been caused by or exacerbated by the performance of
gender transition procedures, whether or not the gender
transition procedure was performed in accordance with state
or federal law;” and

d. “any procedure undertaken because the person suffers from

a physical disorder, physical injury, or physical illness that
would, as certified by a physician, place the person in
imminent danger of death or impairment of a major bodily
function unless treated by the physician.”

S.C. Code Ann. § 44-42-330(1-4).

105. H 4624 states that health care professionals who provide or offer to provide such

“gender transition” treatment and procedures are subject to professional discipline by the

appropriate regulatory agency, S.C. Code Ann. § 44-42-360(A), and may be sued by the Attorney

General or private parties, S.C. Code Ann. § 44-42-360(F). The Ban creates a twenty-one-year

statute of limitations for the private right of action given to minors. S.C. Code Ann. § 44-42-

360(C). The Ban also makes “[a] physician who knowingly performs genital gender reassignment

surgery in violation of this chapter” “guilty of inflicting great bodily injury upon a child”—a

felony. S.C. Code Ann. § 44-42-320(E).

B. Legislative History

106. The General Assembly passed H 4624, despite hearing testimony from South

Carolina doctors about the lifesaving benefits of the banned care for their patients, the rigorous

standards of diagnosis and treatment they follow when providing gender-affirming care to minors,

and the grave harm to their patients’ health and well-being if they are prohibited from receiving

this care. The General Assembly also heard testimony from both transgender South Carolinians,

who shared their experiences of years of struggle, feelings of hopelessness, and desire to end their

lives prior to receiving gender-affirming care, as well as the positive and transformational impact

that gender-affirming medical treatment has on them, and parents of transgender children with

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gender dysphoria, who spoke about the torture in wondering whether their child would die by

suicide prior to gender-affirming treatment and the relief that came from watching their child’s

despair lessen with gender-affirming treatment.

107. At various points during legislative debates, proponents of H 4624 within the

General Assembly defended the bill based on general criticisms and stereotypes of transgender

people. A sponsor of the bill described gender-affirming procedures as “heinous,” and another

house member identified gender dysphoria as the result of “peer pressure.” House Med., Mil., Pub.

& Mun. Affs. Comm. -- 3-M Full Comm. on H.4617 and H.4624 (Jan. 10, 2024) (Statement of Rep.

Pace, Member, H. Comm. on Med., Mil. Pub. and Mun. Affs. at 32:18-21); id. (Statement of Rep.

Beach, Member, H. Comm. on Med., Mil. Pub. and Mun. Affs. at 37:10-15; 39:40-40:00). A third

house member called into question the validity and existence of gender dysphoria. Id. (Statement

of Rep. White, Member, H. Comm. on Med., Mil. Pub. and Mun. Affs. at 59:09-25) (“For me it’s

a mental disorder, for others it’s gender dysphoria.”). Members of the Senate Medical Affairs

Committee compared students coming out to their teachers as transgender to students dressing up

as animals. Senate Comm. on Med. Affs – Senate Med. Affs. Subcomm. on H4624 (Feb. 21, 2024)

(Statements of Sens. Garrett and Loftis, Members, S. Comm. on Med. Affs. at 7:50-9:30).

108. H 4624 is just one piece of a wider discriminatory legislative agenda targeting

transgender persons. During the most recent legislative session, the Senate introduced 12 bills

targeting transgender people, and the House introduced 17, in addition to the H 4624. In June, the

General Assembly passed a state budget for Fiscal Year 2024-2025 that restricts transgender

students’ access to school restrooms and locker rooms. S.C. General Appropriations Bill H. 5100,

Part IB, Section 1, Proviso 1.120.

VI. There Are No Legitimate Justifications for H 4624

109. There are no legislative findings offering any purpose or justification for H 4624.
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110. Purported concerns about protecting minors do not justify categorically prohibiting

medical treatments (like prescribing puberty-delaying medications) only when they are used to

provide gender-affirming medical care to treat transgender adolescents, when the Healthcare Ban

permits the provision of the same medications for purposes other than gender dysphoria treatment.

111. Moreover, the safety and efficacy of this care is supported by decades of research

and clinical evidence. Indeed, the body of research that supports the safety and efficacy of the

banned care is comparable to the research supporting many other treatments—but only gender-

affirming medical care for adolescents is targeted by the Healthcare Ban.

112. The senate sponsor of H 4624, Senator Cash, repeatedly expressed during

committee hearing that the Healthcare Ban was akin to any other South Carolina law limiting the

rights of minors, such as laws prohibiting tattoos and drinking. But tattoos and drinking are not

medical care, and those comparisons are inapt because such laws apply to all minors and do not

employ sex and transgender status-based classifications.

113. Any purported interest in protecting minors from potential physical and emotional

risks associated with the medical treatment at issue likewise cannot justify the Healthcare Ban.

The majority of potential risks and side effects related to puberty-delaying 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 and are comparable to many other forms of

medical treatment patients and their families routinely consent and assent to. But the Healthcare

Ban does not target other forms of medical care that have similar risks (such as other treatments

that carry fertility risks), further indicating that the point of the Healthcare Ban is not to protect

minors from these risks but to discriminate on the basis of sex and transgender status.

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114. Indeed, every medical intervention carries potential risks and potential benefits.

Weighing the potential benefits and risks of the treatment for gender dysphoria is part of the

informed consent process that healthcare providers, parents, and adolescent patients routinely

navigate. Minor patients and their parents often make decisions about treatments with comparable

evidence bases and similar risks as the treatments prohibited by the Healthcare Ban.

115. The current clinical practice guidelines 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

treatment’s potential risks and the minor’s decision-making capacity.

116. There is nothing unique about any of the medically accepted treatments for

adolescents with gender dysphoria that justify singling out these treatments for prohibition.

VII. H 4624 Will Cause Severe Harm to Transgender Youth and Adults

117. Withholding gender-affirming medical treatment from individuals with gender

dysphoria when it is medically indicated puts them at risk of severe and irreparable harm to their

health and well-being.

118. Laws like H 4624 that prohibit access to medically necessary health care gravely

and directly threaten the mental health and physical wellbeing of transgender people in South

Carolina. Individuals with untreated gender dysphoria can suffer serious and life-threatening

medical consequences, including depression, post-traumatic stress disorder, possible self-harm and

suicidal ideation. Studies have found that as many as 40% of transgender people have attempted

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suicide at some point in their lives. 25 Accordingly, major medical and mental health organizations,

including the American Medical Association, the American Psychiatric Association, and the

American College of Obstetricians and Gynecologists, oppose the denial of this medically

necessary care and support public and private health insurance coverage for treatment of gender

dysphoria as recommended by the patient’s physician.

119. The risks of denying medically necessary care to adults are grave. Adults already

receiving this care face additional barriers to, and even termination of, that care, including

necessary therapies and surgery.

120. The risks of denying medically indicated care to individuals with gender dysphoria

are also acute for adolescents.

121. When adolescents have access to puberty-delaying medication and hormone

therapy, which prevent them from going through endogenous puberty and allow them to go

through puberty consistent with their gender identity, their dysphoria decreases, and their mental

health improves. Both clinical experience and multiple medical and scientific studies confirm that

for many young people, this treatment is not only safe and effective, but it is positively

transformative. Indeed, transgender adolescents able to access this medically necessary and

evidence-based medical care often go from suffering to becoming thriving young persons.

122. If patients are not able to start or continue puberty-delaying drugs or hormone

therapy due to the Healthcare Ban, patients will be forced to undergo potentially irreversible

changes from endogenous puberty. This will result in extreme distress for patients who would rely

on medical treatments to prevent the secondary sex characteristics that come with their endogenous

25
Sandy E. James et al., Report of the 2015 U.S. Transgender Survey, Nat’l Ctr. for Transgender
Equal. 5 (Dec. 2016), available at https://transequality.org/sites/default/files/docs/usts/USTS-Full-
Report-Dec17.pdf.
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puberty. These bodily changes can cause severe distress for transgender adolescents with gender

dysphoria that otherwise would have been relieved by medical treatment.

123. 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

breast development can be more difficult (if not impossible) to counteract.

124. 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.

VIII. H 4624 Will Cause Irreparable Harm to Plaintiffs

125. Sterling Misanin. Sterling Misanin is a 32-year-old transgender man.

126. Misanin lives and works in Charleston, South Carolina, and has been a resident of

South Carolina since August 2021. He is a Learning and Development Manager for a global

shipping company.

127. Misanin experiences and has been diagnosed with gender dysphoria.

128. Misanin has experienced feelings of gender dysphoria from a very young age. At

five years old, he asked others to use the pronouns “he” and “him” until his parents told him to

stop. Since he was in elementary school, he was interested in dressing and acting in a typically

masculine manner. In college, he started to understand that the word “transgender” was the right

word to describe his experience, but did not yet feel comfortable coming out. During the 2020

COVID-19 pandemic, Misanin realized that he wanted to live more authentically, and decided to

begin coming out to friends and family.

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129. After coming out, Misanin sought medical care to address his feelings of gender

dysphoria. He spoke with his primary care physician at MUSC and was referred to MUSC

Endocrinology in January 2022. At that time, there was a long wait to meet with endocrinologists,

so Misanin started hormone therapy with a physician at Planned Parenthood in Charleston. Before

beginning treatment, Misanin was counseled about the risks and benefits of hormone therapy and

was given time to carefully consider his treatment plan.

130. After several months of hormone therapy, and consulting with a physician, Misanin

was also able to receive chest masculinization surgery. In order to alleviate feelings of gender

dysphoria, Misanin had been wearing chest binders for a long time and had begun to develop

painful rashes and back pain as a result. Misanin and his provider felt the best solution to improve

his dysphoria would be chest masculinization surgery. Misanin received counseling for this

surgery beginning in March 2022 and underwent chest masculinization surgery in August of 2022.

131. Hormone therapy and chest masculinization brought Misanin a strong sense of

euphoria. He was excited to see more masculine features in his appearance and voice and felt more

comfortable in his body. Misanin believes that this care has improved his well-being and looks

forward to continuing to receive gender-affirming medical care.

132. Misanin does still experience some gender dysphoria and is seeking further

treatment. After counseling with his physicians, Misanin decided to undergo a gender-affirming

hysterectomy, which his surgeon requires for further gender-affirming surgeries like phalloplasty.

133. Misanin and his physicians decided that for quality and continuity of care, MUSC

would be the best place to undergo a hysterectomy. This procedure required Misanin to obtain a

pre-authorization from his private insurer, Aetna. Misanin obtained said pre-authorization and was

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able to schedule a surgery with MUSC. This process took several months. Misanin was eventually

scheduled for surgery on June 28, 2024.

134. Just days before Misanin’s scheduled surgery, he was informed that the surgery was

cancelled and that MUSC would no longer be able to conduct gender-related hysterectomies. After

submitting a formal complaint, it was confirmed to Misanin that this was the case, and he was told

that he would be best served by getting surgery out-of-state or with a private provider.

135. This cancellation has caused Misanin a great deal of hardship. Finding affirming

private providers in South Carolina has been difficult, and Misanin will no longer have continuity

of care at MUSC for this procedure or other future procedures. Misanin eventually wants to

undergo further gender-affirming surgery including phalloplasty, and he will not be able to receive

that care at MUSC.

136. The delay to his most recent surgery has also caused Misanin direct and substantial

harm. Misanin had to restart the arduous pre-authorization process in order to get private coverage

and eventually obtain surgery, a process resulting in months-long delay. Because he has had to

reschedule his surgery and inconvenience his colleagues, Misanin also feels his reputation at work

has been damaged. South Carolina’s interference with his healthcare decisions has deeply

frustrated and harmed Misanin.

137. The Goe Family. Gary Goe and his wife are the parents of Grant, their seventeen-

year-old son, as well as a nineteen-year-old daughter. Gary lives in Anderson County, South

Carolina, where he is a welder. Gary and his wife have built a life and community they love in

South Carolina.

138. Grant is extremely smart and creative. He loves ceramics, creative writing, English

literature, and science and is enjoying his senior year of high school.

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139. Grant Goe is transgender. Although Grant was assigned female at birth, at a young

age Grant knew his gender identity is not female. Puberty caused Grant mental anguish because

he did not feel like he fit in the body he was supposed to. It was difficult for Grant to watch the

boys in his grade go through puberty while he experienced something very different.

140. When Grant was thirteen, he realized he is a boy. Grant asked his friends to use

“he” and “him” pronouns for him. Shortly after, just before high school, Grant told his parents he

is a boy. Gary and his wife were not surprised when they learned Grant is transgender. They had

known something was different about Grant since Kindergarten when he only wanted to hang out

with other boys and do stereotypically boyish things. Having raised their daughter, Gary and his

wife knew Grant was just different. They even referred to Grant using a shortened, gender-neutral

version of his deadname before he came out as transgender.

141. When Grant told his parents about being transgender, Grant was receiving

counseling for anxiety. Gary learned from Grant’s therapist that Grant brought up being

transgender to her. After speaking to Grant and his therapist, Gary and his wife began to research

being transgender, gender dysphoria, and gender-affirming care. Gary and his wife knew little

about being transgender, so they prioritized educating themselves about it and about the options

for treating gender dysphoria.

142. Gary took Grant to see an adolescent medicine specialist, who diagnosed Grant

with gender dysphoria.

143. After receiving that diagnosis, Gary and his wife, with input from Grant, embarked

on a thorough examination of all possible treatments and their side-effects. Gary spoke with

Grant’s medical team and discussed every available option. Gary and his wife discussed the

information and consent forms Grant’s doctors gave them. Grant’s family, including Grant, took

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the decision very seriously. Gary spoke to Grant’s doctors and mental health providers multiple

times. Though their decision was neither easy nor fast, they wanted to be 100% sure of the choice

they made.

144. Eventually, with the support of Grant’s medical team, and with the consent of Gary

and his wife, Grant began hormone replacement therapy (“HRT”) in the form of testosterone, and

a menstrual suppressant. Gary and his wife determined the risks of HRT were far outweighed by

the potential benefits. Before Grant started testosterone, Gary and his wife signed informed consent

forms.

145. Grant started testosterone in 2022. After temporarily suspending his treatment

because of his debilitating fear of needles, Grant’s doctors informed Gary that Grant could receive

testosterone topically and he immediately began doing so in April 2024. Grant has now been on

testosterone consistently for four months. Gary, his wife, and Grant have all noticed a night-and-

day difference in Grant. Grant is happier and excited about the things he loves at school and his

friends. The physical changes caused by testosterone have noticeably boosted Grant’s confidence.

146. Grant is terrified of going off testosterone, which he will have to do by the end of

this year because of the Healthcare Ban. Without access to testosterone, there will be devastating

harm to Grant’s mental health.

147. Grant and his family do not want to leave South Carolina, which would mean

upending their lives during Grant’s senior year. But Gary knows stopping testosterone would be

life-threatening to Grant. He and his wife are so concerned about the harm going off testosterone

would cause that they have been forced to consider moving to a different state.

148. The Noe Family. Nancy Noe is the mother of Nina Noe, her 15-year-old daughter.

Nancy and Nina have lived in South Carolina with their family for their entire lives. Nancy is a

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medical assistant at a pediatric care office in her community, and Nina has just started the tenth

grade. Nina is a budding artist who loves to make music, paint, and knit.

149. Nina Noe is transgender. Nina was assigned male at birth but has known that she is

a girl since she was very young. As a young child, Nina liked to wear Nancy’s makeup and heels,

and identified with the female characters in the television shows she watched. When she was seven

years old, Nina told Nancy that she had a “girl brain” and a “boy body.” She did not have a formal

“coming out” to her parents because her family has always understood and supported her

transgender identity.

150. In the third grade, Nina began to experience heightened discomfort with the

disconnect between her identity and dress at school. Nina worried that her body would start to

change in ways that might upset her. Nina did not want to experience changes of male puberty like

vocal changes or growing facial hair, because she knew these changes would make her feel less

comfortable in her body. As Nina grew more anxious about these changes, her mental health

declined, and she had less interest in activities. Nancy was also concerned about her daughter and

had noticed that she was having a hard time in school and was less interested in her art.

151. Nancy and Nina decided that Nina should visit a doctor who specializes in care for

transgender adolescents and children. Nancy took Nina to visit a pediatric endocrinologist in July

2017. The doctors at that office explained how puberty-delaying medications, hormone therapy,

and other treatments work. They told Nina that medical treatment would not be available until the

onset of puberty and recommended that in the interim Nancy take Nina to see a mental health

provider. Nina began seeing a mental health therapist in 2017 and was subsequently diagnosed

with gender dysphoria.

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152. At that time, Nina began to wear dresses at school, grow out her hair, and began

using “she” and “her” pronouns, at first with family, then also at school. For the most part, her

classmates and teachers were supportive of her social transition. As Nina was able to live more

fully as herself, her mental health improved, and she experienced a stark improvement in stress

and anxiety levels. Nancy noticed that Nina’s interest in schoolwork and hobbies returned.

153. However, in seventh grade, Nina’s anxiety began to worsen again as she started to

experience early signs of male puberty. Nina had a lot of anxiety because she knew these changes

would worsen her gender dysphoria. Nancy and Nina decided to return to a pediatric

endocrinologist, who conducted lab work verifying Nina was beginning endogenous male puberty.

154. Nina’s provider advised that the best course of treatment at this stage in Nina’s

pubertal development would be hormone therapy. Nina’s provider counseled Nancy and Nina on

the benefits and risks of beginning hormone therapy. After weighing these risks and benefits and

further discussions with Nina’s provider, Nina and Nancy decided that Nina should begin hormone

therapy.

155. Nina began hormone treatment with an incrementally increasing dose of estrogen.

Within a few months, Nina started to notice positive changes in her body and her symptoms of

gender dysphoria began to be alleviated.

156. Nina has now been receiving hormone therapy for three years and has observed

marked improvements in her mental health and well-being. She is an outgoing, creative and

confident girl, and Nancy believes this is in large part thanks to the treatment Nina has received.

157. When Nancy and Nina first learned about H 4624, they were very upset. Nina felt

scared and betrayed, and worried about how her life would change if she could not get access to

gender-affirming care. Nancy does not want her daughter’s mental health to slip back to the way

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it once was. Nancy believes that without access to this lifesaving care, Nina would be much worse

off.

158. Nina is insured through her family’s Medicaid coverage. With Medicaid no longer

covering the cost of treatment for Nina’s gender dysphoria, Nancy and Nina’s family will have to

pay prohibitively high out-of-pocket costs for Nina’s care. They will also have to travel across

state lines to receive care and attend medical appointments, resulting in further financial hardship

due to loss of pay for missed work. Nancy is worried about what H 4624 will mean for her family’s

financial future, and for Nina’s mental health and well-being.

159. Jill Ray. Jill Ray is a 36-year-old transgender woman.

160. Ray receives coverage for her health care both through the VA Health Plan—as a

veteran—and as a dependent of her wife’s PEBA plan.

161. Ray experiences and has been diagnosed with gender dysphoria.

162. Before she came out as transgender and began receiving gender-affirming care, Ray

was experiencing such severe depression and anxiety that she did not even feel comfortable leaving

her house.

163. Ray came out as transgender three and a half years ago to her wife, who was not

surprised when Ray told her. With her wife’s affirmation and support, Ray decided to seek out

medical care at the VA. Her primary care doctor referred her to a psychologist, who diagnosed

Ray with gender dysphoria in May 2021.

164. Following the diagnosis of gender dysphoria and working with and under the care

of her medical and mental health providers, Ray began undergoing hormone therapy as medically

necessary treatment for her gender dysphoria in July 2021.

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165. At present, Ray is being prescribed estrogen, progesterone, and spironolactone as

treatment for her gender dysphoria. She sees her endocrinologist approximately every 6 months

and fills her prescriptions every 3 months.

166. Accessing gender-affirming health care is the best decision Ray made for herself.

Hormone therapy allows her to live as the woman she is and has given Ray her life back, but it

does not address the totality of her dysphoria.

167. In consultation with and under the care of her medical and mental health providers,

Ray has decided to seek gender-affirming surgery. Ray obtained referral letters from her

endocrinologist, primary care doctor, and a psychology evaluator at the VA Hospital in South

Carolina in order to receive surgical care.

168. The surgical treatment Ray plans to obtain was covered by her PEBA insurance

until H 4624 went into effect.

169. Ray cannot afford to pay the $100,000-$250,000 that the surgery is likely to cost.

The health care she receives through the VA only covers her hormone replacement therapy.

170. Being able to obtain hormone therapy in the form of estrogen, progesterone, and

spironolactone has made Ray feel like a whole new person. The impact of the gender-affirming

care she has received on her life and wellbeing cannot be overstated. The care she has received has

brought her even closer to her spouse. Ray has formed meaningful, lasting friendships and

community that bring her joy and fulfillment.

171. The difference between the person she was before and the woman she is now is

remarkable. Before coming out she could not leave the house and her relationships were suffering.

Now, she is involved in her community, thriving, confident, and happy.

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172. Although her family, who are religious, were at first hesitant when she told them

she is a woman, they have since understood and accepted Ray for who she is. Ray feels more

comfortable in her relationships with her family now that she can openly be herself.

173. The gender-affirming surgery recommended by Ray’s medical and mental health

providers is medically necessary. It will allow Ray to bring her body more fully into alignment

with who she is. Without gender-affirming surgery, she will continue to experience pain and harm.

Although hormone therapy has significantly improved her wellbeing, without gender-affirming

surgery Ray is unable to be her most authentic and happiest self, spouse, and parent.

174. South Carolina’s law prohibiting Ray’s spouse’s PEBA plan from covering gender-

affirming care has caused Ray a great deal of distress and anxiety. When she learned of the law,

Ray had to put all her plans for her gender-affirming surgery on hold, despite already receiving

referrals and selecting a doctor to perform the procedure.

175. For Ray, it is incredibly stressful and debilitating to have to worry about whether

she will be able to get the medical care that she needs. South Carolina’s decision to deny

transgender people like herself access to medically necessary healthcare and being treated

differently than others solely for being transgender is a burden on Ray’s mental and physical

health.

176. Jane Doe. Jane Doe is a 32-year-old transgender woman.

177. Doe is a physician and resident of Charleston, South Carolina. She lives there with

her wife of eight years. They are expecting a child next year.

178. Doe and her family moved to South Carolina in 2020 in order to pursue an

opportunity with a medical residency program in the state.

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179. Doe receives her healthcare through a state employee healthcare plan administered

by PEBA. She has received healthcare coverage through PEBA since 2020.

180. Doe experiences and has been diagnosed with gender dysphoria. She has dealt with

symptoms of gender dysphoria her entire life, and always felt that she was living in the wrong

body. In her community growing up, she did not feel safe to come out as transgender or voice her

feelings associated with her gender dysphoria. She was particularly worried about her family’s

reaction.

181. When she and her wife were able to move further away from Doe’s family in 2020,

and were financially independent, Doe felt that she was in a position to live fully as herself. Doe

first came out to her wife, who was supportive of her transition.

182. Doe then began therapy with a licensed professional counselor, who diagnosed her

with gender dysphoria in early 2021. After consulting with a doctor and learning more about

gender-affirming care, she began hormone therapy. She has been accessing this treatment for the

last three years. This year, Doe and her medical providers decided that surgery was the next step

in her continuing care and began making plans for Doe to undergo surgical treatment. Doe wanted

to complete this treatment before the end of the year, so that she could be fully recovered in time

for her wife to give birth in February 2025. She has scheduled gender-affirming surgery for

November 11, 2024.

183. Doe feels that her gender-affirming care has improved her life dramatically and

makes her a more complete and authentic person. She is able to provide better care for her patients

when she is the best and most complete version of herself, and this healthcare helps her do that.

184. Doe is a state employee who receives healthcare through PEBA. This plan had

always covered Doe’s hormone therapy, and she understood it would also cover future surgical

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treatment. However, in July of this year, she was informed that PEBA is required to adhere to state

law, thereby indicating to her that PEBA would no longer cover the cost of surgical care. Doe’s

only option for receiving care is now to pay out of pocket, which may cost up to hundreds of

thousands of dollars. Doe will not be able to access this care without insurance coverage due to

the cost.

185. Doe and her wife are heartbroken that the cost of Doe’s medical care will not be

covered by their insurance. Doe was excited for her surgery and hoped that it would further ease

feelings of gender dysphoria. However, without the assistance of their insurance plan, the cost of

paying for Doe’s surgery will be an immense financial burden. Doe and her wife have already

taken on a great deal of medical costs this year as they welcome a child into their home. They are

anxious about the financial future of their family as a result of H 4624’s denial of coverage.

CLASS ACTION ALLEGATIONS

186. Plaintiffs, on behalf of themselves and all similarly situated individuals, bring this

action as a class action pursuant to Rule 23 of the Federal Rules of Civil Procedure.

187. Minor Class: Plaintiffs Grant Goe and Nina Noe assert their claims on behalf of the

following Class: All minors in South Carolina diagnosed with gender dysphoria and whose

medically indicated treatment, as judged by their licensed medical professional, includes or will

include the provision of “gender transition procedures,” as defined by H 4624.

188. Parent Class: Plaintiffs Gary Goe and Nancy Noe assert their claims on behalf of

the following Class: All parents and legal guardians of minors diagnosed with gender dysphoria

and whose medically indicated care, as judged by their licensed medical professional, includes or

will include the provision of “gender transition procedures,” as defined by H 4624.

189. Insurance Class: Plaintiffs Jill Ray, Jane Doe, and Nina Noe assert their claims on

behalf of the following Class: All individuals with gender dysphoria who receive health insurance
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through a state-funded health insurance plan, such as South Carolina Medicaid or South Carolina’s

PEBA, and who, because of S.C. Code Ann. § 44-42-340, are or will be denied coverage for

medically indicated “gender transition procedures,” as defined by H 4624.

190. MUSC Class: Plaintiff Sterling Misanin asserts his claims on behalf of the

following Class: All individuals with gender dysphoria who receive medical care through MUSC

but who, because of S.C. Code Ann. § 44-42-340, are or will be denied medically indicated “gender

transition procedures,” as defined by H 4624.

191. Each Class Representative and the members of the Class they represent have been

equally affected by H 4624. See Motion for Class Certification (“Class Cert. Mot.”) at 12-18.

192. The persons in the proposed Classes are so numerous that joinder of all members

is impracticable. Although the precise number of class members has not been determined at this

time, each Class contains at least 40 members. See Class Cert. Mot. at 11-12; see also In re Zetia

(Ezetimibe) Antitrust Litig., 7 F.4th 227, 234 (4th Cir. 2021) (“As a general guideline, ... a class

that encompasses fewer than 20 members will likely not be certified ... while a class of 40 or more

members raises a presumption of impracticability of joinder based on numbers alone.” (citing

Newberg on Class Actions § 3:12 (5th ed. 2021)).

a. Minor Class: The Williams Institute estimates that there are 3,700
transgender youth ages 13-17 in South Carolina. 26 Of those, on information
and belief, at least 40 were receiving “gender transition procedures” prior
to the enactment of H 4624. See In re Zetia, 7 F.4th at 234.

b. Parent Class: Each member of the Minor Class has at least one
corresponding member in the Parent Class, so the Parent Class includes over
40 members.

26
Jody L. Herman, Andrew R. Flores & Kathryn K. O’Neill, How Many Adults and Youth Identify
as Transgender in the United States?, Williams Institute (June 2022),
https://williamsinstitute.law.ucla.edu/wp-content/uploads/Trans-Pop-Update-Jun-2022.pdf.
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c. Insurance Class: State-funded insurance plans cover hundreds of thousands

of people throughout South Carolina. For example, PEBA’s insurance plans
cover more than 530,000 people throughout South Carolina, 27 and Medicaid
covers more than 1 million people throughout South Carolina. 28 Of those,
on information and belief, at least 40 were receiving “gender transition
procedures” prior to the enactment of H 4624. See In re Zetia, 7 F.4th at
234.

d. MUSC Class: The MUSC Health System admits over 50,000 patients every
year. 29 Of those, on information and belief, at least 40 were receiving
“gender transition procedures” prior to the enactment of H 4624. See In re
Zetia, 7 F.4th at 234.

193. The common questions of law and fact include, but are not limited to:

a. Whether H 4624 and Defendants’ implementation thereof, as applied to

members of the proposed Minor, Parent, Insurance, and MUSC Classes,
violate the Equal Protection Clause of the Fourteenth Amendment to the
U.S. Constitution;

b. Whether H 4624 and Defendants’ implementation thereof, as applied to

members of the MUSC Class and the Insurance Class, violate the
prohibition on sex discrimination under Section 1557 of the Affordable
Care Act;

c. Whether H 4624 and Defendants’ implementation thereof, as applied to

members of the MUSC and Insurance Classes, violate the Americans with
Disabilities Act;

d. Whether H 4624 and Defendants’ implementation thereof, as applied to

members of the MUSC and Insurance Classes, violate the Rehabilitation
Act;

e. Whether H 4624 and Defendants’ implementation thereof, as applied to the

members of the proposed Parent Class, violate the Due Process Clause of
the Fourteenth Amendment to the U.S. Constitution; and

27
State Health Plan: Our membership and participating employers, peba.sc.gov (Jan. 2023)
https://www.peba.sc.gov/value#:~:text=PEBA%E2%80%99s%20insurance%20programs%20co
ver%20more%20than%20530%2C000%20people%20throughout%20South%20Carolina.
28
Fact Sheet: Medicaid in South Carolina, KFF (Aug. 2024) https://files.kff.org/attachment/fact-
sheet-medicaid-state-SC.
29
MUSC Fact Sheet, MUSC (March 2022) https://web.musc.edu/-/sm/global-files/fact-
books/enterprise-wide-fact-book.pdf.
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f. Whether Defendants should be enjoined from enforcing the challenged

provisions.

194. The questions of law and fact listed above will yield common answers for the

Plaintiffs and the proposed Classes.

195. Plaintiffs’ claims are typical of those members of the proposed Classes.

a. Grant Goe is a transgender minor resident of South Carolina and can no

longer access gender-affirming care in South Carolina because of the
Healthcare Ban. Nina Noe is a transgender minor resident of South Carolina
and can no longer access gender-affirming care in South Carolina because
of the Healthcare Ban. Grant Goe and Nina Noe, representing the Minor
Class, and members of the proposed Classes share the same legal claims
under the Equal Protection Clause. See Class Cert. Mot. at 3-4, 16.

b. Gary Goe is a resident of South Carolina and a parent to Grant Goe, a

transgender minor; Gary Goe can no longer make decision regarding his
child’s medical care with respect to gender dysphoria, because of the
Healthcare Ban. Nancy Noe is a resident of South Carolina and a parent to
Nina Noe, a transgender minor; Nancy Noe can no longer make decision
regarding her child’s medical care with respect to gender dysphoria,
because of the Healthcare Ban. Gary Goe and Nancy Noe, representing the
Parent Class, and members of the proposed Classes share the same legal
claims under the Equal Protection Clause and the Due Process Clause. See
Class Cert. Mot. at 5, 16.

c. Jill Ray, Jane Doe, and Nina Noe are transgender residents of South
Carolina who can no longer receive state-funded insurance coverage for
their gender-affirming care because of the Public Funds Restriction. Ray,
Doe, and Nina Noe, representing the Insurance Class, and members of the
proposed Insurance Class, share the same legal claims under the Equal
Protection Clause, Affordable Care Act, Americans with Disabilities Act
and the Rehabilitation Act. See Class Cert. Mot. at 16-17.

d. Sterling Misanin is a transgender resident of South Carolina who can no

longer receive necessary gender-affirming surgery because of the Public
Funds Restriction. Misanin, representing the MUSC Class, and members of
the proposed MUSC Class share the same legal claims under the Equal
Protection Clause, the Affordable Care Act, the Americans with Disabilities
Act, and the Rehabilitation Act. See Class Cert. Mot. at 17.

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196. Plaintiffs will fairly and adequately represent the interests of the proposed Classes

and have retained counsel experienced in complex class action litigation. See Class Cert. Mot. at

18-19.

197. Class treatment is appropriate under Fed. R. Civ. P. 23(b)(2) because Defendants

have acted on grounds that apply generally to the proposed Classes such that final injunctive relief

or corresponding declaratory relief would be appropriate for the proposed Classes as a whole.

CAUSES OF ACTION

COUNT ONE
H 4624 VIOLATES THE FOURTEENTH AMENDMENT’S GUARANTEE OF EQUAL
PROTECTION UNDER THE LAW

(ALL PLAINTIFFS AND ALL CLASSES AGAINST DEFENDANT WILSON)

(PLAINTIFFS NINA NOE AND NANCY NOE AGAINST DEFENDANT KERR)
(PLAINTIFFS JILL RAY, JANE DOE, AND NINA NOE AND THE INSURANCE
CLASS AGAINST DEFENDANTS BOYKIN AND KERR)
(PLAINTIFF STERLING MISANIN AND THE MUSC CLASS AGAINST
DEFENDANTS COLE AND THE MUSC BOARD DEFENDANTS)

198. Plaintiffs repeat and reallege the allegations in previous paragraphs of this

Complaint as if fully alleged herein.

199. Defendants Wilson, Kerr, Boykin, Cole, and the MUSC Board 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.

200. 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.

201. H 4624’s Healthcare Ban bars the provision to minors of various forms of medically

necessary care only when the care is “provided or performed for the purpose of assisting an

individual with a physical gender transition,” meaning “the process in which a person goes from

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identifying with and living as a gender that corresponds to his or her sex to identifying with and

living as a gender different from his or her sex.” S.C. Code Ann. §§ 44-42-310(5)-(6); 44-42-320.

It permits the use of these treatments for other purposes. S.C. Code Ann. § 44-42-330.

202. In addition, H 4624’s Public Funds Restriction prohibits the use of state funds

“directly or indirectly” only when they are spent for care “provided or performed for the purpose

of assisting an individual with a physical gender transition,” meaning “the process in which a

person goes from identifying with and living as a gender that corresponds to his or her sex to

identifying with and living as a gender different from his or her sex.” S.C. Code Ann. §§ 44-42-

310(5)-(6); 44-42-340.

203. H 4624’s Medicaid Restriction similarly prohibits the South Carolina Medicaid

Program from “reimburs[ing] or provid[ing] coverage” for care “provided or performed for the

purpose of assisting an individual with a physical gender transition,” meaning “the process in

which a person goes from identifying with and living as a gender that corresponds to his or her sex

to identifying with and living as a gender different from his or her sex.” S.C. Code Ann. §§ 44-42-

310(5)-(6); 44-42-320; 44-42-350. It permits the expenditure of state funds on and Medicaid

coverage for the provision of these medications and surgical interventions for other purposes. S.C.

Code Ann. § 44-42-330.

204. In doing so, H 4624 explicitly classifies based on sex and transgender status,

including classifying Minor Plaintiffs Grant Goe and Nina Noe and Adult Plaintiffs Sterling

Misanin, Jill Ray, and Jane Doe and the Class Members they represent, based on their transgender

status and sex, including their failure to conform to stereotypes and expected behavior associated

with their sex designated at birth. This classification is not substantially related to an important

government interest.

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205. H 4624 also classifies parents of transgender youth on the basis of their children’s

sex and transgender status. This includes the Parent Plaintiffs Gary Goe and Nancy Noe, and the

Parent Class, who are denied the ability to secure urgently needed medical care for their children

that other parents can obtain, on the basis of transgender status and sex-based grounds. This

classification is not substantially related to an important government interest.

206. In addition to facially classifying based on sex and transgender status, H 4624 was

passed in part because of its effects on transgender people, not in spite of them, and triggers

heightened scrutiny for this reason as well.

207. H 4624 was enacted with the specific intent to discriminate against transgender

people.

208. 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

justification for the differential treatment.

209. Transgender people have obvious, immutable, and distinguishing characteristics

that define that class as a discrete group. These characteristics bear no relation to transgender

people’s abilities to perform in or contribute to society.

210. Transgender people have historically been subject to discrimination in South

Carolina and across the country and remain a very small minority of the American population that

lacks political power.

211. 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

cannot be required to abandon it as a condition of equal treatment.

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212. H 4624 does not substantially advance an interest in 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 them access to necessary care without justification for its limitation only on

the rights of transgender minors. H 4624 does nothing to protect the health or well-being of adults,

either; South Carolina offers no justification why state-funded procedures for transgender people

are prohibited while the same state-funded procedures are permitted for cisgender persons.

213. H 4624’s discriminatory treatment of healthcare for transgender adolescents is not

adequately tailored to any sufficiently important government interest, nor is it even rationally

related to any legitimate government interest. South Carolina cannot point to any legitimate

government interest that justifies infringing only on the rights of transgender minors and

transgender recipients of state-funded care.

214. H 4624’s targeted prohibition on medically necessary care for transgender

individuals 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.

215. H 4624 violates the equal protection rights of the Minor Plaintiffs, the Minor Class,

the Parent Plaintiffs, the Parent Class, the Adult Plaintiffs, the MUSC Class, and the Insurance

Class.

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COUNT TWO
THE HEALTHCARE BAN VIOLATES THE RIGHT TO PARENTAL AUTONOMY
GUARANTEED BY THE FOURTEENTH AMENDMENT’S DUE PROCESS CLAUSE

(PARENT PLAINTIFFS AND PARENT CLASS AGAINST DEFENDANT WILSON)

(PLAINTIFF NANCY NOE AGAINST DEFENDANT KERR)

216. Plaintiffs repeat and reallege the allegations in previous paragraphs of this

Complaint as if fully alleged herein.

217. Wilson and Kerr are governmental actors and/or employees acting under color of

State law for purposes of 42 U.S.C. § 1983 and the Fourteenth Amendment.

218. Wilson is charged with enforcing compliance with H 4624. S.C. Code Ann. § 44-

42-360(F).

219. Kerr oversees and directs all functions at DHHS, including Medicaid, of which

Nancy Noe’s daughter Nina is a beneficiary.

220. 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,

custody, and control of their children.

221. That fundamental right of parents includes the right to direct the medical care of

their minor children, including by seeking and following medical advice.

222. 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.

223. The Healthcare Ban’s prohibition against well-accepted medical treatments for

adolescents with gender dysphoria deprives South Carolina parents of their fundamental right to

make decisions concerning the care of their children. The Healthcare Ban also discriminates

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against the Parent Plaintiffs and the Parent Class with respect to the exercise of this fundamental

right.

224. The Healthcare 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 without justification

for its limitation only on the rights of transgender minors and their parents.

225. The Healthcare Ban’s prohibition against the provision of medically accepted

treatments for adolescents with gender dysphoria is not narrowly tailored to serve a compelling

government interest, nor is it rationally related to any legitimate government interest. South

Carolina cannot point to any legitimate government interest that justifies infringing only on the

rights of transgender minors and their parents.

226. The Healthcare Ban violates the fundamental rights of the Parent Plaintiffs and

Parent Class.

227. The Public Funding Ban’s prohibition on the use of state funds, including Medicaid

funds, for well-accepted medical treatments for adolescents with gender dysphoria deprives South

Carolina parents of children on Medicaid and other state-funded insurance of their fundamental

right to make decisions concerning the care of their children.

228. The Public Funding Ban violates the fundamental rights of the Nancy Noe, whose

daughter is a beneficiary of Medicaid.

COUNT THREE
THE PUBLIC FUNDING AND MEDICAID RESTRICTIONS VIOLATE SECTION 1557
OF THE AFFORDABLE CARE ACT

(PLAINTIFFS JILL RAY, JANE DOE, NINA NOE, AND THE INSURANCE CLASS
AGAINST DEFENDANTS PEBA, BOYKIN, DHHS, AND KERR)

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(PLAINTIFF MISANIN AND THE MUSC CLASS AGAINST DEFENDANTS COLE,

THE MUSC BOARD DEFENDANTS, and MUSC)
(PLAINTIFF NINA NOE AGAINST DEFENDANTS DHHS AND KERR)

229. Plaintiffs repeat and reallege the allegations in previous paragraphs of this

Complaint as if fully alleged herein.

230. Section 1557 of the Affordable Care Act, 42 U.S.C. § 18116, provides, in relevant

part that, “an individual shall not, on the ground prohibited under … title IX of the Education

Amendments of 1972 (20 U.S.C. §§ 1681 et seq.)”—which prohibits 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 which is receiving Federal

financial assistance.” 42 U.S.C. § 18116(a); see 45 C.F.R. § 92.3.

231. Discrimination on the basis of nonconformity with sex stereotypes, transgender

status, gender, gender identity, gender transition, and sex characteristics are all forms of

discrimination encompassed by the prohibition of discrimination on the basis of sex under Section

1557.

232. Defendant DHHS is engaged in a health program or activity in that it is responsible

for many aspects of public health in South Carolina and provides health services to many South

Carolinians across the state. Defendant DHHS 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. Defendant Kerr oversees and

directs all functions at DHHS, including its Medicaid operations.

233. PEBA is a government program administered by Defendant Boykin that receives

federal financial assistance such that it is a “covered entity” for purposes of Section 1557 of the

ACA.

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234. MUSC is a medical university administered by the MUSC Board Defendants and

Defendant Cole that receives federal financial assistance such that it is a “covered entity” for

purposes of Section 1557 of the ACA.

235. Jill Ray, Jane Doe, Nina Noe, and the Insurance Class, seek the benefits of

healthcare coverage funded by the state.

236. Plaintiffs and the Insurance Class will be denied those benefits and subjected to

discrimination on account of their sex because the Public Funds Restriction prohibits entities

receiving public funds from using those funds “for the purpose of assisting an individual with a

physical gender transition.” S.C. Code Ann. §§ 44-42-310(6); 44-42-340.

237. Sterling Misanin and the MUSC Class seek the benefits of healthcare from

providers funded by the state.

238. Misanin and the MUSC Class will be denied those benefits and subjected to

discrimination on account of their sex because the Public Funds Restriction prohibits entities

receiving public funds from using those funds “for the purpose of assisting an individual with a

physical gender transition.” S.C. Code Ann. §§ 44-42-310(6); 44-42-340.

239. Nina Noe seeks the benefits of Medicaid.

240. Nina Noe will be denied those benefits and subjected to discrimination on account

of her sex because the Medicaid Restriction prohibits entities receiving public funds from using

those funds “for the purpose of assisting an individual with a physical gender transition.” S.C.

Code Ann. §§ 44-42-310(6); 44-42-350.

241. The Public Funds Restriction and the Medicaid Restrictions necessarily require the

DHHS, PEBA, MUSC, Boykin, Kerr, Cole, and the MUSC Board Defendants to violate Section

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1557 by requiring that they discriminate on the basis of sex and transgender status, to the

substantial injury of the Plaintiffs and Class Members who will be deprived of medical care.

242. The Plaintiffs and the Insurance and MUSC Classes are therefore entitled to

declaratory and injunctive relief prohibiting the Defendants from complying with the Public Funds

and Medicaid Restrictions. Without injunctive relief from the discriminatory law, Plaintiffs and

the Class they represent will continue to suffer irreparable harm in the future.

COUNT FOUR
THE PUBLIC FUNDS RESTRICTIONS AND THE MEDICAID RESTRICTIONS
VIOLATE THE MEDICAID ACT’S COMPARABILITY AND AVAILABILITY
REQUIREMENTS

(PLAINTIFF NINA NOE AGAINST DEFENDANTS DHHS AND KERR)

243. Plaintiffs repeat and reallege the allegations in previous paragraphs of this

Complaint as if fully alleged herein.

244. The Medicaid Act’s Comparability Requirement, 42 U.S.C. § 396a(a)(10)(B)(i),

provide that the “medical assistance made available to [eligible individuals] shall not be less in

amount, duration, or scope than the medical assistance made available to” other eligible

individuals. The Medicaid Act’s Availability Requirement, 42 C.F.R. § 440.230(b), requires that

South Carolina cover both mandatory and optional services in sufficient “amount, duration, and

scope to reasonably achieve its purpose.”

245. Defendant DHHS is the “single state agency” charged with administering Medicaid

program in South Carolina. 42 U.S.C. § 1396a(a)(5); S.C. Code Ann. § 44-6-30 (2024). Defendant

Kerr oversees and directs all functions at DHHS, including its Medicaid operations.

246. Nina Noe seeks the benefits of Medicaid.

247. Nina Noe will be denied those benefits on account of her gender dysphoria

diagnoses because the Medicaid Restriction prohibits Medicaid from covering treatments provided

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“for the purpose of assisting an individual with a physical gender transition.” S.C. Code Ann. §§

44-42-310(6); 44-42-350.

248. The Public Funds and Medicaid Restrictions, and Defendants’ refusal, based on the

Restrictions, to provide coverage for services for the treatment of gender dysphoria to Noe, while

covering the same services for other South Carolina Medicaid beneficiaries with different

diagnoses, violate the Medicaid Act’s Comparability and Availability Requirements, 42 U.S.C. §

1396a(a)(10)(B)(i), 42 C.F.R. § 440.230(b), which are enforceable by Plaintiffs under 42 U.S.C.

§ 1983.

COUNT FIVE
H 4624 VIOLATES THE AMERICANS WITH DISABILITIES ACT

(PLAINTIFF STERLING MISANIN AND THE MUSC CLASS AGAINST MUSC)

(PLAINTIFFS JANE DOE, JILL RAY, AND NINA NOE AND THE INSURANCE
CLASS AGAINST PEBA AND DHHS)

249. Plaintiffs repeat and reallege the allegations in previous paragraphs of this

Complaint as if fully alleged herein.

250. Plaintiffs and the Classes they represent suffer from a “disability” within the

meaning and scope of 42 U.S.C. § 12102 (2009) based on their gender dysphoria. Williams v.

Kincaid, 45 F.4th 759, 766 (4th Cir. 2022). Thus, Plaintiffs and the Classes they represent are

members of the class of persons protected by the ADA.

251. The ADA prohibits public entities from discriminating against an individual with a

disability, or denying the benefits of the services, programs, or activities of a public entity or entity

receiving federal funds to a person based on their disability.

252. PEBA, DHHS, and MUSC are state government agencies or instrumentalities of

the State and are therefore public entities within the meaning of the ADA.

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253. PEBA, DHHS, and MUSC, through their agents, violated Title II of the ADA by

discriminating against Plaintiffs and the Classes they represent on the basis of their disability and

denying them the benefits of public services, programs, and activities because of their disability.

Specifically, PEBA, DHHS, and MUSC have violated Title II’s non-discrimination mandate by:

a. implementing and enforcing H 4624’s irrational and

discriminatory provisions, including the Healthcare Ban, the
Public Funding Restriction, and the Medicaid Restriction,
that only apply to individuals seeking treatment for gender
dysphoria, a protected disability; and

b. applying those discriminatory provisions against Plaintiffs,

thereby depriving them of medically necessary treatment
and causing avoidable and gratuitous pain and suffering.

254. Such actions and behaviors have and will continue to physically, emotionally, and

psychologically harm Plaintiffs and the Classes they represent.

255. PEBA, DHHS, and MUSC are not entitled to immunity under the Eleventh

Amendment for this cause of action.

256. As a direct and legal result of PEBA’s actions and omissions, Plaintiffs Doe, Ray,

and the Insurance Class have suffered and continue to suffer injury, including, but not limited to,

serious physical, psychological, and emotional harm and mental anguish, distress, humiliation, and

indignity.

257. As a direct and legal result of DHHS’s actions and omissions, Plaintiff Nina Noe

and the Insurance Class have suffered and continue to suffer injury, including, but not limited to,

serious physical, psychological, and emotional harm and mental anguish, distress, humiliation, and

indignity.

258. As a direct result of MUSC’s actions and omissions, Plaintiff Misanin and the

MUSC Class have suffered and continue to suffer injury, including, but not limited to, serious

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physical, psychological, and emotional harm and mental anguish, distress, humiliation, and

indignity.

COUNT SIX
H 4624 VIOLATES THE REHABILITATION ACT

(PLAINTIFF STERLING MISANIN AND THE MUSC CLASS AGAINST MUSC)

(PLAINTIFFS JANE DOE, JILL RAY, AND NINA NOE AND THE INSURANCE
CLASS AGAINST PEBA AND DHHS)

259. Plaintiffs repeat and reallege the allegations in previous paragraphs of this

Complaint as if fully alleged herein.

260. Based on their diagnoses of gender dysphoria, Plaintiffs and the Classes they

represent suffer from a “disability” and are members of the class of persons protected under

Section 504 of the Rehabilitation Act. The act prohibits entities receiving federal funds from

discriminating against an individual with a disability, or denying the benefits of the services,

programs, or activities of a public entity or entity receiving federal funds to a person with a

disability.

261. PEBA, DHHS, and MUSC receive federal financial assistance for health care

services through multiple avenues, including Medicaid, which is funded by both the federal

government and the state.

262. PEBA, DHHS, and MUSC discriminated against Plaintiffs and the Classes they

represent on the basis of their disability and denied them the benefits of public services, programs,

and activities as a result of their disability by, among other things, failing to provide adequate and

necessary medical treatment and depriving Plaintiffs and the Classes they represent of the benefits

of programs and activities. Such actions and behaviors have detrimentally affected the health of

Plaintiffs and the Classes they represent.

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263. PEBA, DHHS, MUSC, and their agents violate Section 504 of the Rehabilitation

Act, which prohibits discrimination on the basis of physical and mental disability and protects

persons like Plaintiffs and the Classes they represent from the injuries set forth herein.

264. PEBA, DHHS, and MUSC are not entitled to immunity under the Eleventh

Amendment for this cause of action.

265. As a direct and legal result of PEBA’s actions and omissions, Plaintiffs Doe, Ray,

and the Insurance Class have suffered and continue to suffer injury, including, but not limited to,

serious physical, psychological, and emotional harm and mental anguish, distress, humiliation, and

indignity.

266. As a direct and legal result of DHHS’s actions and omissions, Plaintiff Nina Noe

and the Insurance Class have suffered and continue to suffer injury, including, but not limited to,

serious physical, psychological, and emotional harm and mental anguish, distress, humiliation, and

indignity.

267. As a direct result of MUSC’s actions and omissions, Plaintiff Misanin and the

MUSC Class have suffered and continue to suffer injury, including, but not limited to, serious

physical, psychological, and emotional harm and mental anguish, distress, humiliation, and

indignity.

REQUEST FOR RELIEF

WHEREFORE, Plaintiffs respectfully pray that this Court:

A. Enter a judgment declaring that S.C. Code Ann. §§ 44-42-310 et seq., which

categorically prohibits the provision of medically necessary gender-affirming medical care for the

treatment of gender dysphoria to minors and prohibits state funding of gender-affirming care for

all individuals, as applied to Plaintiffs and the putative Classes:

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i. violates the Equal Protection Clause of the Fourteenth Amendment by

discriminating against

a. transgender adolescents on the basis of sex and transgender status,

b. the parents of transgender children with regards to

1. their exercise of the right to parental autonomy and

2. their ability to secure necessary medical care for their

children that other parents can obtain, and

c. individuals who receive gender-affirming care from providers who

receive state funding or whose health insurance coverage is state-

funded;

and is therefore unenforceable;

ii. violates the Due Process Clause of the Fourteenth Amendment by infringing

upon parents’ fundamental right to make decisions concerning the care of their

children, and is therefore unenforceable;

iii. violates Section 1557 of the Affordable Care Act by discriminating against

transgender individuals on the basis of sex, and is therefore unenforceable; and

iv. violates the comparability and availability requirements of the Medicaid Act by

discriminating against transgender individuals on the basis of sex, and is

therefore unenforceable;

v. violates Title II of the ADA by discriminating against transgender individuals

on the basis of their disability and denying them the benefits of public services,

programs, and activities because of their disability;

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vi. violates Section 504 of the Rehabilitation Act by discriminating against

transgender individuals on the basis on their disability and denying them the

benefits of public services, programs, and activities because of their disability;

B. Issue preliminary and permanent injunctions enjoining Defendants, their

employees, agents, and successors in office and those in active concert or participation with them

from implementing or enforcing H 4642 against the Plaintiffs and the putative Class Members;

C. Waive the requirement for the posting of a bond of security for the entry of

temporary and preliminary relief;

D. Award Plaintiffs their costs and expenses, including reasonable attorneys’ fees,

pursuant to 42 U.S.C. § 1988 and all other applicable statutes and sources of law; and

E. Grant such other relief as the Court deems just and proper.

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Dated: August 29, 2024

Respectfully submitted,

/s/ Meredith McPhail

Allen Chaney (Fed. Id. No. 13181)
Meredith McPhail (Fed. Id. No. 13500)
ACLU OF SOUTH CAROLINA
P.O. Box 1668
Columbia, SC 29202
T: 864-372-6881
achaney@aclusc.org
mmcphail@aclusc.org

/s/ Sruti Swaminathan

Sruti Swaminathan*
Harper Seldin*
AMERICAN CIVIL LIBERIES UNION
FOUNDATION
125 Broad St., Fl 18
New York, NY 10004
T: 212-549-2500
hseldin@aclu.org
sswaminathan@aclu.org

/s/ Julie Singer

David S. Flugman*
Corey Stoughton*
Julie Singer*
SELENDY GAY PLLC
1290 Avenue of the Americas
New York, NY 10104
T: 212-390-9000
dflugman@selendygay.com
cstoughton@selendygay.com
jsinger@selendygay.com

* Application for Admission Pro Hac Vice

Forthcoming

Attorneys for Plaintiffs

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