Anna Lange v. Houston County, Georgia

• Court: Court of Appeals for the Eleventh Circuit
• Decided: September 9, 2025
• Docket: 22-13626
• Status: Published

Opinion

USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 1 of 108

FOR PUBLICATION

In the United States Court of Appeals For the Eleventh Circuit ____________________ No. 22-13626 ____________________

ANNA LANGE, Plaintiff-Appellee, versus

HOUSTON COUNTY, GEORGIA, HOUSTON COUNTY SHERIFF CULLEN TALTON, in his official capacity, Defendants-Appellants, HOUSTON COUNTY BOARD OF COMMISSIONERS, et al., Defendant. ____________________ Appeal from the United States District Court for the Middle District of Georgia D.C. Docket No. 5:19-cv-00392-MTT ____________________ USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 2 of 108

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Before WILLIAM PRYOR, Chief Judge, and JORDAN, ROSENBAUM, JILL PRYOR, NEWSOM, BRANCH, GRANT, LUCK, LAGOA, BRASHER, ABUDU, KIDD, and WILSON, ∗ Circuit Judges. BRASHER, Circuit Judge, delivered the opinion of the Court, in which WILLIAM PRYOR, Chief Judge, and NEWSOM, BRANCH, GRANT, LUCK, and LAGOA, Circuit Judges, joined. NEWSOM, Circuit Judge, filed a concurring opinion. ROSENBAUM, Circuit Judge, filed an opinion concurring in the judg- ment. JILL PRYOR, Circuit Judge, filed a dissenting opinion, in which JORDAN, ABUDU, KIDD, and WILSON, Circuit Judges, joined. ABUDU, Circuit Judge, filed a dissenting opinion. WILSON, Circuit Judge, filed a dissenting opinion, in which ABUDU and KIDD, Circuit Judges, joined. BRASHER, Circuit Judge: Anna Lange, a transgender woman and deputy at the Hou- ston County Sheriff’s Office, sought a male-to-female sex change surgery 1 and requested that the County’s employer-provided

∗ Senior Circuit Judge Wilson elected to participate in this decision pursuant

to 28 U.S.C. § 46(c). 1 The Supreme Court has held that “sex . . . is an immutable characteristic

determined solely by the accident of birth.” Frontiero v. Richardson, 411 U.S. 677, 686 (1973). We nevertheless refer to this surgical procedure as a “sex change” because that is the terminology used by the policy and the parties. USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 3 of 108

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health insurance pay for it. But because the County’s insurance pol- icy excludes “[d]rugs for sex change surgery” and “[s]ervices and supplies for a sex change and/or the reversal of a sex change,” the insurer denied Lange’s request. Doc. 205 at 3–4. Lange then sued the County for disparate treatment because of sex under Title VII of the Civil Rights Act of 1964, and the district court held, among other things, that the plan’s exclusion facially discriminates because of sex as a matter of law. We took this appeal en banc to answer whether the insur- ance policy facially violates Title VII. We conclude that it does not. Many of Lange’s arguments have been rejected by the Supreme Court. See United States v. Skrmetti, 145 S. Ct. 1816 (2025). Although the plan does not cover sex change surgeries, it does not treat any- one differently based on a protected characteristic. Because the ex- clusion is not facially discriminatory under Title VII, we reverse the district court’s judgment, vacate the permanent injunction, and re- mand for further proceedings consistent with this opinion. I.

Anna Lange, a natal male, has been a deputy with the Hou- ston County Sheriff’s Office since 2006. In 2017, Lange was diag- nosed with gender dysphoria and began to openly identify as a woman. According to one of Lange’s expert witnesses, gender dys- phoria is a “serious medical condition” that creates “an intense and persistent discomfort” with one’s biological anatomy. Doc. 132-3 at 6–7. Most transgender individuals seek some level of medical ser- vices in connection with their diagnoses. Those services range USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 4 of 108

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from mental health services, to counseling, to hormone therapy, to sex change surgeries. A sex change surgery is a suite of medical procedures that can vary in purpose, cost, and complexity. It may include “[c]hest reconstruction surgery”; “[g]enital reconstruction surgeries” such as a “penectomy (removal of the penis), orchiectomy (removal of the testes), vaginoplasty, clitoroplasty, and/or vulvoplasty”; and other surgeries such as “facial feminization surgery, liposuction, lipofilling, voice surgery, thyroid cartilage reduction, gluteal aug- mentation . . . , and hair reconstruction, among others.” Id. at 9. As a deputy at the Houston County Sheriff’s Office, Lange participates in the County’s health insurance plan. Doc. 205 at 3. That plan, in total, excludes coverage for 68 medical categories and 29 pharmaceutical categories. Among the excluded medical cate- gories are dental and vision care, elective abortions, contraceptives, hearing aids, fertility treatment, and oral surgeries. The plan ex- cludes all coverage for “[s]ervices or supplies for male or female sexual problems,” “[d]rugs to treat sexual or erectile problems,” and treatments and drugs for “[i]nfertility.” Id. 70, 72, 74. The plan also excludes coverage for cosmetic surgeries. And, since at least 1998, the plan has excluded “[d]rugs,” “[s]ervices[,] and supplies for a sex change and/or the reversal of a sex change.” Id. at 72, 74. Because the plan does not exclude coverage for all treat- ments related to gender dysphoria, Lange took advantage of the plan to pay for hormones, endocrinologist visits, and psychologist visits. Lange testified to that effect, explaining that mental health USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 5 of 108

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services and “medication”—which Lange clarified includes hor- mones—were covered, and that insurance paid “the bulk of the charge” for Lange’s endocrinology visits. Doc. 137-3 at 49–50; Doc. 150-18, Ex. 36, at 11–12. As additional treatment for gender dysphoria, Lange sought a sex change surgery to alter Lange’s male genitals to appear more like female genitals. Under this procedure, “the testicles will be re- moved, the urethra will be shortened, and the penile and scrotal skin will be used to line the neovagina, the space between the rec- tum and the prostate and the bladder.” Doc. 144-1 at 7. After the procedure, the patient must undergo an “extensive regimen of post-surgery dilatation to prevent the closure of the neovagina.” Id. Because no surgeon who could perform this procedure was availa- ble where Lange lived, Lange sought this care in New York from a specialist in sex change surgery. See Doc. 144-1 at 8 (“there’s no one who does bottom surgery in [Lange’s] community”); 179-3 at 44– 45. Citing the County’s exclusion, the insurer that administers the County’s plan denied coverage for Lange’s sex change surgery. Lange then sued the County under Title VII for discrimination be- cause of sex. The parties disputed why the County adopted the ex- clusion, and the district court held that the dispute was genuine. See Doc. 205 at 21 n.11 (“Because there is a genuine dispute of ma- terial fact as to whether the adoption and maintenance of the Ex- clusion was done with discriminatory intent, the Court does not reach the question of whether the Exclusion would subsequently USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 6 of 108

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survive intermediate scrutiny.”). But the district court held that the County’s reasons for the policy did not matter under Title VII. See id. at 27 n.15 (“Although the parties debate whether the County’s professed desire to save money is relevant to disprove discrimina- tory intent or to provide a legitimate nondiscriminatory reason ap- propriate in a McDonnell Douglas analysis, that debate has no place here.”). The district court concluded that the County’s insurance policy violated Title VII on its face, granted summary judgment for Lange, and permanently enjoined the exclusion of sex change sur- gery from the County’s insurance policy. The County appealed. After a divided three-judge panel of this Court affirmed the district court, Lange v. Houston County, 101 F.4th 793, 798–99 (11th Cir.), reh’g en banc granted, opinion vacated, 110 F.4th 1254 (11th Cir. 2024), we voted to take the case en banc and asked the parties to brief one question: whether the insurance policy at issue, which covers medically necessary treatments for certain diagnoses but bars coverage for Lange’s sex change surgery, facially violates Title VII. II.

“We review a district court’s grant of summary judgment de novo, viewing all the evidence, and drawing all reasonable factual inferences, in favor of the nonmoving party.” Baxter v. Santiago-Mi- randa, 121 F.4th 873, 883 (11th Cir. 2024) (quotation omitted). USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 7 of 108

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III.

Health insurance is a heavily regulated industry. Congress has enacted statutes that bar insurance companies from denying coverage to individuals with preexisting conditions. 42 U.S.C. §§ 300gg–1(a), 300gg–3(a), 300gg–4(a). Other statutes prohibit insur- ers from charging higher rates to individuals based on their medical history. Id. §§ 300gg, 300gg–4(b). And yet more statutes require in- surers to cover specific conditions, treatments, and periods of hos- pitalization. Id. § 18022(b); 29 U.S.C. §§ 1185–1185a. Title VII, however, does not directly regulate insurance pol- icies. Instead, Title VII makes it unlawful for a covered employer to “discriminate against any individual with respect to his compen- sation, terms, conditions, or privileges of employment, because of such individual’s race, color, religion, sex, or national origin.” 42 U.S.C. § 2000e-2(a)(1). Employer-provided health insurance is a “privilege of employment.” See Newport News Shipbuilding & Dry Dock Co. v. EEOC, 462 U.S. 669, 682 (1983). So, if an employer pro- vides health insurance, its policy cannot discriminate based on a protected characteristic. Lange has brought a disparate treatment claim against the County under Title VII. The Supreme Court has held that Title VII prohibits employers “from firing employees on the basis of homo- sexuality or transgender status” when “discrimination based on ho- mosexuality or transgender status necessarily entails discrimina- tion based on sex.” Bostock v. Clayton County., 590 U.S. 644, 669, 680 (2020). Lange argues that the sex change exclusion in the County’s USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 8 of 108

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insurance policy violates Title VII because it reflects a “formal, fa- cially discriminatory policy requiring adverse treatment of” transgender employees based on sex. Hazen Paper Co. v. Biggins, 507 U.S. 604, 610 (1993). Unlike other Title VII claims, a disparate treat- ment claim based on a facially discriminatory policy “does not de- pend on why the [defendant] discriminates but rather on the ex- plicit terms of the discrimination.” Automobile Workers v. Johnson Controls, Inc., 499 U.S. 187, 199 (1991). The question for us is whether the County’s insurance plan facially discriminates based on a protected characteristic. Lange makes four arguments that it does. None works. We will address each argument in turn. First, Lange argues that the policy discriminates on the basis of sex. Under Bostock, we apply a “simple test” for sex discrimina- tion—“change one thing at a time and see if the outcome changes.” 590 U.S. at 656, 671. “[I]f changing the employee’s sex would have yielded a different choice by the employer,” then the employer has discriminated based on sex. Id. at 659–60. Citing Bostock, Lange ar- gues that the plan discriminates based on sex because it would have covered the requested surgery if Lange were born a female and de- nied coverage only because Lange was born a male. We disagree. The Supreme Court recently rejected Lange’s interpretation of Bostock in United States v. Skrmetti, 145 S. Ct. 1816 (2025). There, the plaintiffs argued that a Tennessee law discriminated based on sex when it disallowed certain treatments for gender dysphoria in children but allowed those treatments for other medical USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 9 of 108

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conditions. The plaintiffs “urge[d]” the Court “to apply Bostock’s reasoning” to their equal protection claim. Id. at 1834. The Court assumed the plaintiffs were correct that Bostock’s reasoning applied outside the Title VII context. But it held that, “[u]nder the reason- ing of Bostock, neither [the plaintiff’s] sex nor his transgender status is the but-for cause of his inability to obtain testosterone.” Id. at 1834. More specifically, the Court reasoned that the law did not classify based on sex because “the law does not prohibit conduct for one sex that it permits for the other.” Id. at 1831. Instead, the Court explained that the challenged law “divides minors into two groups: those who might seek puberty blockers or hormones to treat the excluded diagnoses, and those who might seek puberty blockers or hormones to treat other conditions.” Id. at 1833. Thus, “[i]f a transgender boy seeks testosterone to treat his gender dys- phoria, [the law] prevents a healthcare provider from administer- ing it to him”—and “[i]f you change his biological sex from female to male, [the law] would still not permit him the hormones he seeks.” Id. at 1834. But, if the same hypothetical child seeks testos- terone for a qualifying diagnosis, that child could obtain the testos- terone regardless of his sex. Id. The Supreme Court’s reasoning in Skrmetti applies equally here. The County’s policy does not pay for a sex change operation for anyone regardless of their biological sex. See id. at 1831 (“[N]o minor may be administered [the prohibited drugs] to treat gender dysphoria, gender identity disorder, or gender incongruence; USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 10 of 108

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minors of any sex may be administered puberty blockers or hor- mones for other purposes”). Lange is a natal man. If Lange were instead a natal woman who wanted a female-to-male sex change, the insurance policy would not pay for it. Or if Lange were a natal woman who sought coverage for the same male-to-female sex change that Lange received (perhaps for a male dependent), the County’s policy would operate in the same way—it would deny coverage. Nothing about the policy exclusion turns on whether the County’s employee is a man or woman. The same is true when we consider the specific procedures that were part of Lange’s sex change surgery. Lange’s sex change surgery involved the removal of the testicles, the shortening of the urethra, and the creation of a neovagina. Let’s change “one thing” and assume Lange were a natal woman instead of a natal man: would the insurance policy have covered any of those procedures as part of a sex change? Again, the answer is no. Some of those pro- cedures would be impossible for a person with a female anatomy to undergo. See, e.g., id. at 1830 (explaining that when “a transgender boy (whose biological sex is female) takes puberty blockers to treat his gender incongruence, he receives a different medical treatment than a boy whose biological sex is male who takes puberty blockers to treat his precocious puberty”). And oth- ers would be denied to both natal men and natal women as part of a sex change. For example, if a natal woman needed a neovagina as part of a sex change surgery—perhaps as a reversal of a previous female-to-male sex change—the plan would deny coverage for that procedure just as it denied coverage for Lange as a natal man. On USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 11 of 108

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the other hand, these procedures would be covered when required because of medical conditions, such as cancer or injuries from a car accident, for an employee of either sex (subject to the policy’s other exclusions). “Under the logic of Bostock, then, sex is simply not a but-for cause.” Id. at 1835. Second, even if the exclusion does not discriminate based on sex, Lange says that the County’s plan discriminates based on transgender status because it does not cover treatments for gender dysphoria to the same extent that it covers treatments for other conditions. Neither the Supreme Court nor this Court has held that transgender status is separately protected under Title VII apart from sex. And Bostock did not add transgender status, as a category, to the list of classes protected by Title VII. To the contrary, the Court expressly denied that it was answering any question other than “whether an employer who fires someone simply for being . . . transgender has discharged or otherwise discriminated against that individual ‘because of such individual’s sex’” within the meaning of Title VII’s plain terms. Bostock, 590 U.S. at 681 (quoting 42 U.S.C. § 2000e-2(a)(1)). But, even if this theory were viable under Title VII, the County’s plan does not facially discriminate based on transgender status. Again, the Supreme Court rejected a very similar argument in Skrmetti. There, the plaintiffs argued that the Tennessee law dis- criminated based on transgender status because it prohibited healthcare providers from administering puberty blockers or hor- mones to treat gender dysphoria, although it allowed them to be USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 12 of 108

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prescribed for other conditions. The Court, however, held that the law did not “classify on the basis of transgender status.” Skrmetti, 145 S. Ct. at 1833. The Court recognized that “a key aspect of any medical treatment” is “the underlying medical concern the treat- ment is intended to address.” Id. at 1830. Applying that insight to the discrimination question, the Court held that the state law did not discriminate based on transgender status because it did “not exclude any individual from medical treatments on the basis of transgender status but rather remove[d] one set of diagnoses—gen- der dysphoria, gender identity disorder, and gender incongru- ence—from the range of treatable conditions.” Id. at 1833. Although the plaintiffs’ claim in Skrmetti arose under the Equal Protection Clause, the Court expressly held that the state statute at issue did not discriminate based on transgender status un- der the same Title VII precedents that we must apply here. This was so, the Court explained, because “changing a minor’s sex or transgender status does not alter the application” of the challenged statute. Id. at 1834. The Court reasoned that, because a “transgender boy” could “obtain the [treatment] regardless of his sex or transgender status” if he had a “permissible diagnos[is],” id., the challenged law did not discriminate based on transgender sta- tus. Id. The Court said point blank: “Under the reasoning of Bos- tock, neither [the plaintiff’s] sex nor his transgender status is the but- for cause of his inability to obtain” the prohibited treatment. Id. (emphasis added). USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 13 of 108

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For all the same reasons, we likewise conclude that the County’s plan does not facially discriminate based on transgender status. Like the law at issue in Skrmetti, the County’s policy is a “classification based on medical use.” Id. at 1833. The plan does not say, for example, that transgender employees must pay more than nontransgender employees or that transgender employees or their dependents receive reduced benefits. See, e.g., Newport News, 462 U.S. at 684 (“[T]he husbands of female employees receive[d] a spec- ified level of hospitalization coverage for all conditions,” but “the wives of male employees receive[d] such coverage except for preg- nancy-related conditions”); L.A. Dep’t of Water & Power v. Manhart, 435 U.S. 702, 705 (1978) (policy “required female employees to make monthly contributions to the fund which were 14.84% higher than the contributions required of comparable male em- ployees”). Instead, as we have already explained, the County’s plan would cover the procedures that make up a sex change for other purposes, such as treatment for cancer or reconstructive surgery following a car accident, whether or not the employee who needed those procedures was transgender. See Skrmetti, 145 S. Ct. at 1834 (“[I]f he had such a diagnosis, he could obtain the testosterone re- gardless of his sex or transgender status.”). Our dissenting colleagues say that the Supreme Court’s ex- tensive discussion of Bostock in Skrmetti is either distinguishable or dicta or both. We disagree. In Skrmetti, the plaintiffs argued that, under the reasoning of Bostock, they had been discriminated against based on sex and transgender status. Id. at 1834. See also id. at 1874- 78 (Sotomayor, J., dissenting) (making the same argument). The USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 14 of 108

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Supreme Court’s analysis of Bostock is why the Court rejected that argument. The Court assumed without deciding that Bostock ap- plied to the plaintiffs’ equal protection claim and concluded that their argument failed because, “[f]or reasons we have already ex- plained, changing the minor’s sex or transgender status does not alter the application of” the challenged state law. Id. at 1834. It ex- pressly held that, “[u]nder the reasoning of Bostock” and “[u]nder the logic of Bostock,” there was no discrimination based on sex or transgender status for reasons that (as we have already explained) apply equally here. Id. at 1834–35. It is passing strange that our dissenting colleagues rely ex- tensively on Bostock, and, at the same time, reject the Supreme Court’s own explanation of what Bostock means.2 We have said many times that “[t]he holding of a case comprises both the result of the case and those portions of the opinion necessary to that re- sult.” E.g., United States v. Gillis, 938 F.3d 1181, 1198 (11th Cir. 2019) (quotation marks omitted). Under that standard, Skrmetti’s holding

2 Our dissenting colleague, Judge Jill Pryor, also criticizes the Supreme Court’s

discussion of Bostock in Skrmetti as “implicitly rel[ying] on since-rejected rea- soning from Geduldig [v. Aillo, 417 U.S. 484 (1974)] and [General Electric Co. v.] Gilbert [429 U.S. 125 (1976)].” Of course, those cases were about pregnancy discrimination (which is not an issue in this case), not alleged transgender dis- crimination (which is the issue in this case, was the issue in Bostock, and was the issue in Skrmetti). And it’s not clear how a lower court judge’s idiosyncratic interpretation of a Supreme Court decision from four decades ago could trump the plain language of a Supreme Court decision from four months ago. In any event, our opinion in this case says nothing about Geduldig, Gilbert, or the Pregnancy Discrimination Act. USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 15 of 108

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about the meaning of Bostock is binding on us unless and until the Supreme Court says otherwise. As lower court judges, we cannot shut our ears when the Supreme Court tells us how to apply its precedents. Third, Lange argues that the plan facially discriminates based on sex stereotypes. Title VII forbids treating employees dif- ferently because of sex-based stereotypes about men or women. See Price Waterhouse v. Hopkins, 490 U.S. 228, 251 (1989). But this exclu- sion is not based on stereotypes. Cf. Skrmetti, 145 S. Ct. at 1832 (“the plaintiffs’ allegations of sex stereotyping are misplaced”). If the plan discriminated against participants because of gender stereotypes, it would presumably cover procedures to align a participant’s physi- cal characteristics with those of his or her biological sex. But it does not do that. On the contrary, the plan excludes coverage for a suite of medical procedures that change the appearance of a person’s sex organs—regardless whether the goal is to differ from, or align with, natal sex. Fourth, Lange argues that the plan’s exclusion facially vio- lates Title VII because it penalizes a person for transitioning. But this argument is simply a mischaracterization of the plan’s func- tion. The fact that the plan excludes coverage for one treatment for gender dysphoria is not a penalty in any sense of the word. The plan does not, for example, impose a surcharge on employees who have undergone a sex change. Instead, the plan declines to extend a benefit—namely, coverage for a sex change operation. And that benefit is declined to everyone. USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 16 of 108

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Finally, although Lange implies that the County’s policy lacks a legitimate justification, that question is well outside the scope of this appeal. The question here is about alleged discrimina- tion on the face of the policy. The district court expressly held that the County’s reason for the policy was a matter of genuine dispute and could not be resolved at summary judgment. See Doc. 205 at 21 n.11 (holding that “a genuine dispute of material fact” exists as to “whether the adoption and maintenance of the Exclusion was done with discriminatory intent”). Lange did not challenge the district court’s conclusion on appeal. The panel, of course, did not reach the issue. See Lange v. Houston County, 101 F.4th 793, 799 (11th Cir. 2024) (holding that the policy is “facially discriminatory” and going no further), reh’g en banc granted, opinion vacated, 110 F.4th 1254 (11th Cir. 2024). And we did not ask the parties to brief that issue en banc—telling the parties instead to address whether the policy “facially violates Title VII” no matter its justification. In short, the County’s plan does not facially violate Title VII. The County’s plan draws a line between certain treatments, which it covers, and other treatments, which it does not. That line may or may not be appropriate as a matter of health care policy, but it is not facial discrimination based on protected status. IV.

Because we conclude that the plan is not facially discrimina- tory under Title VII, we REVERSE the district court’s judgment, VACATE the permanent injunction, and REMAND for further proceedings consistent with this opinion. USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 17 of 108

22-13626 NEWSOM, J., Concurring 1

NEWSOM, Circuit Judge, concurring: I concur. Lange’s Title VII challenge is foreclosed by the por- tion of the Supreme Court’s recent opinion in United States v. Skrmetti, 145 S. Ct. 1816 (2025), that addresses and explains its ear- lier decision in Bostock v. Clayton County, 590 U.S. 644 (2020). I write separately simply to emphasize that I don’t take either Skrmetti or today’s en banc opinion to collapse the separate analyses that apply to claims under Title VII and the Fourteenth Amendment’s Equal Protection Clause. For reasons I’ll try to explain briefly, I don’t think there would be any valid justification for doing so. Title VII and the Equal Protection Clause have certain com- monalities, to be sure. They share some of the same conceptual “space” and, as relevant here, both prohibit sex discrimination in certain circumstances. But they’re also different in some very sig- nificant ways. Most importantly by far, there’s the issue of text: The two provisions use different words. The Equal Protection Clause says that “[n]o State shall . . . deny to any person within its jurisdiction the equal protection of the laws.” U.S. Const. amend. XIV, § 1. Ti- tle VII states that “[i]t shall be an unlawful employment practice for an employer . . . to discriminate against any individual with respect to his compensation, terms, conditions, or privileges of employ- ment, because of such individual’s race, color, religion, sex, or na- tional origin.” 42 U.S.C. § 2000e-2(a)(1). A court’s most fundamen- tal job is to interpret the words and phrases used in written docu- ments—in particular, words and phrases authored by others, be USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 18 of 108

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they the Framers, legislators, regulators, or private parties. Ideally, the court will do so by giving those words and phrases the mean- ings “they conveyed to reasonable people at the time they were written.” Antonin Scalia & Bryan A. Garner, Reading Law: The In- terpretation of Legal Texts 16 (2012). Because the Equal Protection Clause and Title VII were adopted at different times—indeed, nearly a full century apart—and employ different terms, their re- spective interpretations can’t simply be merged into an undifferen- tiated whole. The textual differences, while paramount, are just the tip of the iceberg—the distinctions run deep and wide: • To start with the most obvious, the Equal Protection Clause and Title VII have different sources: The former is constitutional; the latter is statutory. • The two also have different fields of operation: The Equal Protection Clause applies to all manner of discrim- inatory actions, but only those taken by government en- tities, see, e.g., NCAA v. Tarkanian, 488 U.S. 179, 191 (1988); Title VII reaches only employment-related discrimina- tion, but applies to private entities as well as public, see, e.g., Hazelwood Sch. Dist. v. United States, 433 U.S. 299, 304 n.7 (1977). • Another difference, noted by the most (in a good way) “notorious” sex-equality advocate of her generation: “The Equal Protection Clause . . . prohibits only inten- tional discrimination,” while “Title VII . . . aims to USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 19 of 108

22-13626 NEWSOM, J., Concurring 3

eliminate all forms of employment discrimination, unin- tentional as well as deliberate.” Ricci v. DeStefano, 557 U.S. 557, 627 (2009) (Ginsburg, J., dissenting). • Yet another: At least as implemented by the Supreme Court, the provisions operate on different objects, so to speak: The Equal Protection Clause focuses on classifi- cations (race, sex, etc.) and groups (black people, white people, men, women, etc.), see, e.g., Skrmetti, 145 S. Ct. at 1828–29, whereas in a Title VII case, the court’s “focus should be on individuals, not groups,” Bostock, 590 U.S. at 658; see also L.A. Dep’t of Water & Power v. Manhart, 435 U.S. 702, 709 (1978) (observing that Title VII “requires that [courts] focus on fairness to individuals rather than fairness to classes”). • One more: At least under current law, the two provisions entail different doctrinal frameworks. If a court applying the Equal Protection Clause concludes, for instance, that a state statute or policy classifies on the basis of sex, it must then march through a multi-part heightened-scru- tiny analysis in order to determine whether a violation has occurred. See, e.g., United States v. Virginia, 518 U.S. 515, 531–34 (1996). Title VII, by contrast, is effectively a toggle: If a court concludes that an employer’s action discriminates on the basis of sex, it is verboten per se. See, e.g., Bostock, 590 U.S. at 659. USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 20 of 108

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So, the Court is quite right to reject Lange’s Title VII claim— the portion of Skrmetti that explains Bostock requires as much. But to be clear, at least as I see things, the analyses that govern chal- lenges brought under Title VII and the Equal Protection Clause re- main separate—as they must, for both textual and doctrinal rea- sons.1

1 In his dissent, Judge Wilson seems to agree that Title VII and equal-protec-

tion challenges should be adjudged according to their own respective stand- ards and that reviewing courts shouldn’t conflate the two. See Wilson Dissent- ing Op. at 10 et seq. The problem for Judge Wilson is that, as he acknowledges, in Skrmetti—a case that arose under the Equal Protection Clause—the Su- preme Court “conducted an analysis under Bostock.” Id. at 10. And it doesn’t matter that the Court “declined to address ‘whether Bostock’s reasoning reaches beyond the Title VII context,” id. (quoting Skrmetti, 145 S. Ct. at 1834– 35)—because the case before us arises squarely within “the Title VII context.” So whether or not it was strictly necessary, or even wise, for the Skrmetti Court to address Bostock in the course of deciding an equal-protection case, the fact is it did so. And we can’t ignore what it said and did. See, e.g., Schwab v. Crosby, 451 F.3d 1308, 1325 (11th Cir. 2006) (“[T]here is dicta, and then there is dicta, and then there is Supreme Court dicta.”). USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 21 of 108

22-13626 ROSENBAUM, J., Concurring in the Judgment 1

ROSENBAUM, Circuit Judge, concurring in the judgment: I concur in the judgment because I agree that United States v. Skrmetti, 145 S. Ct. 1816 (2025), binds us in this case. Skrmetti held that a Tennessee law prohibiting prescribing puberty blockers to minors for gender-affirming purposes does not violate the Equal Protection Clause. Skrmetti reached this conclusion because it de- termined the law neither discriminated based on sex, nor discrimi- nated based on transgender status since, the Court said, the law does not classify by sex or transgender status. 1 To be sure, Lange brings a sex-discrimination claim under Title VII, not the Equal Protection Clause. And Skrmetti is an Equal Protection Clause case. But the first step in both Title VII and Equal Protection Clause cases requires us to determine whether the law or program at issue classifies on the basis of a protected status. Though Title VII and Equal Protection Clause analyses don’t always use the same understandings of discriminatory classi- fications to determine the answer to that first step, Skrmetti says it applied both understandings of discriminatory classifications and

1 More precisely, Skrmetti addressed the constitutionality of a law that “pro-

hibit[ed] a healthcare provider from ‘[s]urgically removing, modifying, alter- ing, or entering into tissues, cavities, or organs of a human being,’ or ‘[p]re- scribing, administering, or dispensing any puberty blocker or hormone,’ for the purpose of (1) ‘[e]nabling a minor to identify with, or live as, a purported identity inconsistent with the minor’s sex,’ or (2) ‘[t]reating purported discom- fort or distress from a discordance between the minor’s sex and asserted iden- tity.’” 145 at 1826 (internal citations omitted). USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 22 of 108

2 ROSENBAUM, J., Concurring in the Judgment 22-13626

arrived at the same answer: the law in Skrmetti did not use a dis- criminatory classification. In particular, the Court held that a law that prohibited healthcare providers from prescribing puberty blockers and hor- mones to minors—but only for a diagnosis of gender dysphoria— did not classify by sex or transgender status. And because a party argued that Title VII’s methodology requires the conclusion that the law classified by sex, Skrmetti had to consider whether it did. Skrmetti determined that Title VII demands no such conclusion. That binds us. As I explain later in this opinion, I haven’t found a meaning- ful way to distinguish Houston County’s healthcare plan—which excludes from coverage certain surgeries, but only if they involve (in the words of the plan) a “sex change” (a procedure one would have only to address gender dysphoria)—from the law at issue in Skrmetti. So Skrmetti requires me to conclude that the plan doesn’t classify by sex. I say this with deep regret for three reasons. First, as Judge Wilson explains, see Wilson Op. at 2 n.2, the record compellingly reveals that Houston County precludes sex-affirming surgeries for discriminatory reasons. Despite this, our decision today leaves Lange with no remedy for her disparate-treatment claim. Second, most respectfully, Skrmetti’s conclusion that the law there didn’t discriminate by sex or transgender status, even under Title VII’s understanding of discriminatory classifications, conflicts with dec- ades of Title VII jurisprudence culminating in Bostock v. Clayton USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 23 of 108

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County, 590 U.S. 644 (2020), the opinion on which it relies. In my view, Skrmetti incorrectly applies Bostock’s test, so it wrongly deter- mines that the Skrmetti law did not classify by sex. And third, Skrmetti’s determination that the law there didn’t discriminate by sex or transgender status, even under Title VII’s understanding of discriminatory classifications, effectively imports the reasoning of Geduldig v. Aiello, 417 U.S. 484 (1974), into Title VII jurisprudence. But Congress expressly amended Title VII to reject the holding and reasoning of Geduldig, overriding the Supreme Court’s extension of the reasoning of that case to the statute. The Supreme Court itself recognized this in Newport News Shipbuilding & Dry Dock Co. v. Equal Employment Opportunity Commission, 462 U.S. 669, 678 (1983) (ac- knowledging that “[w]hen Congress amended Title VII in 1978, it unambiguously expressed its disapproval of both the holding and the reasoning of the Court in the [General Electric Co. v.] Gilbert[2] deci- sion,” which had applied Geduldig’s understanding of discrimina- tory classifications to the Title VII context (emphasis added)). Geduldig is a fifty-one-year-old opinio non grata that the Court had essentially exiled—even in the Equal Protection Clause con- text—until just recently. For good reason. Most respectfully, Geduldig’s reasoning is illogical and cannot peacefully coexist with the Supreme Court’s discrimination jurisprudence—or even with the concept of discrimination.

2 429 U.S. 125 (1976). USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 24 of 108

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But Geduldig’s doctrinal shortcomings shouldn’t surprise us. After all, the Supreme Court issued it in 1974—two years before the Court first articulated its modern-day framework for how courts analyze sex-discrimination claims under the Equal Protection Clause. See Craig v. Boren, 429 U.S. 190, 197 (1976). 3 So the Court couldn’t have designed Geduldig to be consistent with the body of antidiscrimination law that came after it. 4 I write separately to explain how Skrmetti incorrectly im- ports Geduldig’s reasoning into Title VII and to respectfully add my voice to the chorus of those urging the Court to reconsider Geduldig’s reasoning and Skrmetti. 5

3 In stating the standard, Craig held that “[t]o withstand constitutional chal-

lenge, . . . classifications by gender must serve important governmental objec- tives and must be substantially related to achievement of those objectives.” 429 U.S. at 197. In other words, under our modern Equal Protection frame- work, “sex-based classifications warrant heightened scrutiny.” Skrmetti, 145 S. Ct. at 1828. 4 See Leah Litman, The Archaic Sex-Discrimination Case the Supreme Court Is Re-

viving, THE ATLANTIC (June 24, 2025), https://www.theatlan- tic.com/ideas/archive/2025/06/supreme-court-sex-discrimination- skrmetti/683296/ [https://perma.cc/XK4B-G6T7] (observing that “height- ened judicial scrutiny” didn’t apply “[a]t the time Geduldig was decided”). 5 See, e.g., Skrmetti, 145 at 1880 (Sotomayor, J., dissenting) (“Geduldig was ‘egre-

giously wrong’ when it was decided . . . .” (quoting Coleman v. Court of Appeals of Md., 566 U.S. 30, 56–57 (2012) (Ginsburg, J., dissenting))); AT&T Corp. v. Hulteen, 556 U.S. 701, 728 n.17 (2009) (Ginsburg, J., dissenting) (collecting sources critiquing Geduldig’s reasoning); Bray v. Alexandria Women’s Health Clinic, 506 U.S. 263, 327 (1993) (Stevens, J., dissenting); Sylvia A. Law, Rethink- ing Sex and the Constitution, 132 U. PA. L. REV. 955, 983–84 (1984) (“Criticizing Geduldig has since become a cottage industry. Over two dozen law review USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 25 of 108

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This concurrence proceeds in three parts. First, I summarize how discrimination jurisprudence generally works. Then, I explain why Geduldig clashes with that framework, is illogical even on its own terms, and should be overturned. And last, I show how Skrmetti wrongly applied Bostock and, in the process, imported Geduldig’s reasoning when it determined that the law there did not classify by sex or transgender status, even under Title VII’s meth- odology for determining discriminatory classes. I. The Equal Protection Clause’s Two-Step Approach to Discrimination Law To explain why Geduldig was wrongly reasoned, we must think about how discrimination jurisprudence generally works. But first, a remark on terminology: I use the phrase “dis- crimination jurisprudence” throughout this concurrence as a short- hand. Of course, the right to be free from discrimination has many sources in American law. These include the Equal Protection Clause of the Fourteenth Amendment, Title VII of the Civil Rights Act of 1964, and more specific employment-related statutes—like the Equal Pay Act of 1963, the Age Discrimination in Employment Act of 1967, the Pregnancy Discrimination Act of 1978, and the

articles have condemned both the Court’s approach and the result. . . . Even the principal scholarly defense of Geduldig admits that the Court was wrong in refusing to recognize that the classification was sex-based . . . .”); ERWIN CHEMERINSKY, CONSTITUTIONAL LAW: PRINCIPLES AND POLICIES 779 (4th ed. 2011) (“It is hard to imagine a clearer sex-based distinction [than the one in Geduldig].”). USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 26 of 108

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Americans with Disabilities Act of 1990, among others. So of course, the analysis of discrimination claims isn’t identical across statutes, 6 or between Title VII and the Equal Protection Clause. Equal Protection Clause discrimination jurisprudence uses a two-step analysis to determine whether a violation has occurred. At the first step, we ask “whether a law ‘differentiate[s] on the basis of [a suspect classification, like sex, race, national origin, or reli- gion].’” Skrmetti, 145 S. Ct. at 1875 & n.9 (Sotomayor, J., dissent- ing) (quoting Sessions v. Morales-Santana, 582 U.S. 47, 58 (2017)). If so, we proceed to the second step. At step two, we consider whether the state has met its “demanding” “burden” of showing that a law that differentiates on the basis of a suspect classification on its face has an “exceedingly persuasive” justification. United States v. Virginia, 518 U.S. 515, 533 (1996). Similarly, for a facial challenge like Lange’s, Title VII prece- dents like Bostock “ask[] the very same question our equal protec- tion precedents do” at step one of the analysis—namely, “whether a law ‘differentiate[s] on the basis of gender.’” Skrmetti, 145 S. Ct.

6 That said, Congress passed many of the employment-discrimination laws

that postdate Title VII to expand some of Title VII’s protections to other groups. See Abigail C. Modjeska, 1 EMPLOYMENT DISCRIMINATION LAW § 1:1 (3rd ed.). “Because of this historical development, the early Title VII cases gave rise to many of the substantive doctrines that are now applied in all em- ployment discrimination cases.” Id.; see also, e.g., Lewis v. City of Union City, 918 F.3d 1213, 1221 n.7 (11th Cir. 2019) (en banc) (“McDonnell Douglas’s burden- shifting framework applies to claims arising under a host of federal antidis- crimination laws.”). USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 27 of 108

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at 1875 & n.9 (Sotomayor, J., dissenting) (quoting Sessions, 582 U.S. at 58). If so, that’s pretty much the end of the Title VII inquiry because “Title VII offers employers no similar opportunity [to step two of the Equal Protection Clause framework] justify discrimina- tion . . . .” Id. at 1875 n.9. Importantly, both Title VII and the Equal Protection Clause ask whether a law classifies by a protected class at the level of the individual. See Bostock, 590 U.S. at 658 (stating that in analyzing Title VII claims, “our focus should be on individuals, not groups”); Adarand Constructors, Inc. v. Peña, 515 U.S. 200, 227 (1995) (“[T]he . . . Fourteenth Amendment[] to the Constitution protect[s] per- sons, not groups.” (emphases in original)). But while the Court’s “cases discussing constitutional principles [in the Equal Protection context] can provide helpful guidance in th[e] statutory context” of Title VII, the analyses aren’t entirely coextensive. See Ricci v. DeSte- fano, 557 U.S. 557, 582 (2009) (emphasis added). In particular, at step one of the analysis, they differ when it comes to how each line of precedent treats Geduldig—which un- dergirded the Supreme Court’s decision in Skrmetti. This is significant. It means the analysis can differ in how we answer the question whether a given law classifies on the basis of sex. I explain this further in the next section. In Skrmetti’s Equal Protection context, the Court embraced Geduldig’s logic. See 145 S. Ct. at 1833–34. But in the context of Title VII, the Court—and USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 28 of 108

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Congress, for that matter—have expressly rejected that reasoning.7 See J. Pryor Dissenting Op. at 2–3; see also Newport News, 462 U.S. at 678. So to be sure, the analyses under the Equal Protection Clause and Title VII aren’t identical. And this concurrence isn’t, of course, a treatise on nondiscrimination law, nor does it intend to serve as a comprehensive primer on all the nuanced distinctions among different species of discrimination claims. Rather, what matters, for our purposes, is discussing the high-level two-step analysis that generally applies to disparate-treatment discrimina- tion claims under (as relevant here) the Equal Protection Clause and how the first step of that analysis differs under Title VII, even though we ask the same question about whether a law classifies on a suspect (or protected, in Title VII cases) classification basis in both frameworks.

7 Perhaps it may seem unusual that the same question may generate two dif-

ferent answers in two different contexts. But sometimes that’s what the law requires. Here, we are considering a constitutional provision (the Equal Pro- tection Clause of the Fourteenth Amendment) and a statutory one (Title VII). The Supreme Court gets to interpret the Constitution. See generally Marbury v. Madison, 5 U.S. 137 (1803). But Congress can pass laws telling the Court when it’s erred in construing Congress’s legislation—through a congressional override. See, e.g., Deborah Widiss, Undermining Congressional Overrides: The Hydra Problem in Statutory Interpretation, 90 TEX. L. REV. 859, 875 (2012) (ex- plaining that congressional overrides are “a crucial mechanism of maintaining legislative supremacy in the statutory realm”). That’s exactly what Congress did when it amended Title VII and enacted the Pregnancy Discrimination Act: it overrode the Supreme Court’s Geduldig reasoning as applied to the Title VII context. See Newport News, 462 U.S. at 678. USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 29 of 108

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With that background in mind, I zoom in on the Equal Pro- tection framework. As I’ve mentioned, Equal Protection Clause discrimination jurisprudence generally employs a two-step analysis. See, e.g., Rus- sell W. Galloway, Jr., Basic Equal Protection Analysis, 29 SANTA CLARA L. REV. 121, 123–24 (1989). At the first step, we consider whether the challenged program classifies on the basis of a suspect classification—that is, a classification like sex, race, national origin, or religion. See id. We call them “suspect” classifications because legislatures have historically unjustly discriminated against those groups, simply because their members are born into them. See, e.g., id. at 133–36, 145 n.111 (“Intensified scrutiny is appropriate because, his- torically, [protected-class members] have been the victims of dis- crimination.”); Sessions, 582 U.S. at 62–64. But the Constitution considers all Americans to be born equal. See, e.g., U.S. CONST. amend. XIV, § 1; AKHIL REED AMAR, AMERICA’S CONSTITUTION: A BIOGRAPHY 380–85 (2005). So when a law classifies on the basis of a suspect classification, we must conduct a methodical, searching inquiry into it to ensure that the law doesn’t violate the Constitu- tion. See Galloway, supra, at 123–24. That’s why the answer to the first question of Equal Protec- tion Clause discrimination analysis—whether the law classifies by a suspect classification—determines what we do at the second step of the analysis. If the program doesn’t classify on the basis of a sus- pect classification, we apply rational-basis scrutiny to the law or USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 30 of 108

10 ROSENBAUM, J., Concurring in the Judgment 22-13626

program. And rational-basis scrutiny means the program will usu- ally survive constitutional review because we need only hypothe- size a rational reason for the program to uphold it. 8 We generally trust the legislature has a good reason for classifying on these bases. See id. But if the program classifies on the basis of a suspect classifi- cation, we apply heightened scrutiny in reviewing it. Depending on the suspect classification, that level of scrutiny can be interme- diate or strict. But either way, it is far harder for a program to sur- vive heightened scrutiny than rational-basis review. That is, we look with a skeptical eye towards these classifications because of legislatures’ historical practice of unjustly discriminating on these bases. We need to make sure that the real purpose behind the chal- lenged law is not to treat a group of people unequally, as can often be the case with these classifications. See id. Because whether a program classifies on the basis of a sus- pect classification often determines whether it can survive the sec- ond step of the Equal Protection Clause discrimination-jurispru- dence framework, it is critical to get the first step of discrimination analysis right. But Geduldig didn’t. And in the process, it illogically distorted and hopelessly confused the definition of “classification.”

8 That is not to say that rational-basis review never invalidates a law. If a law

classifies by a class that is not protected “not to further a proper legislative end but to make them unequal to everyone else,” it will not pass rational-basis scrutiny. Romer v. Evans, 517 U.S. 620, 625 (1996). After all, “[e]qual protection of the laws is not achieved through indiscriminate imposition of inequalities.” Id. (citations and quotation marks omitted). USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 31 of 108

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As a result, Geduldig subjects laws that we should be skeptical of, in light of our country’s history of sex discrimination, to the deference of rational-basis review. And in fact, as I explain in the next section, Geduldig itself does just that. II. Geduldig’s Illogical Misapplication of Discrimination Law In Geduldig, the Court analyzed whether California’s disabil- ity insurance plan violated the Equal Protection Clause. All work- ers—both male and female—had to pay 1% of their wages into the insurance plan. But the state defined “disability” to exclude cover- age for “certain disabilities resulting from pregnancy.” 417 U.S. at 486. Even though only women can get pregnant and the pro- gram didn’t exclude coverage for any male-exclusive conditions, see id. at 489, the Court determined that the program didn’t classify by sex, id. at 494–97. The Court reasoned that the program “divided potential recipients into two groups: ‘pregnant women and non- pregnant persons,’” and “women fell into both groups[.]” Skrmetti, 145 S. Ct. at 1833 (quoting Geduldig, 417 U.S. at 496 n.20). So, the Court concluded, “the program did not discriminate against women as a class.” Id. Rather, the Court characterized the pro- gram as doing no more than “remov[ing] one physical condition— pregnancy—from the list of compensable disabilities.” Geduldig, 417 U.S. at 496 n.20. And in determining that the program didn’t classify by sex, the Court also considered that the cost of the USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 32 of 108

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program would increase if it covered pregnancy-related disabilities. See id. at 493–94. Geduldig’s classification determination is wrong for at least four reasons. First, it is factually incorrect to say that the program, which excluded coverage for pregnancy-related conditions, which only fe- males can experience, while covering male-only medical condi- tions, did not classify by sex. 9 Indeed, in its most classic formula- tion, a classification is based on sex when an individual assigned female at birth is disadvantaged relative to a comparable individual assigned male at birth (or vice versa), because of that person’s sex.10 That’s exactly what occurs when females who have sex-linked medical conditions receive no protection while males with sex- linked medical conditions do. Second, Geduldig’s logic embraces historic sex stereotyping, which flouts the purpose of antidiscrimination law. At step one, we must decide whether a law differentiates on the basis of a sus- pect classification because laws that do may have been driven by sex stereotyping or other forms of discriminatory animus. And ironically, the line Geduldig draws—on pregnancy—buys into the

9 We know that the insurance plan in Geduldig covered male-only medical con-

ditions because it covered prostatectomies, among other “disabilities . . . that affect only or primarily [the male] sex.” See id. at 501 (Brennan, J., dissenting). 10 For ease of reading, for the remainder of this opinion, I refer to those as-

signed female at birth as “females” and those assigned male at birth as “males.” USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 33 of 108

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exact kind of historic sex stereotyping that our antidiscrimination jurisprudence is designed to root out. Third, Geduldig effectively applies a special and unwarranted exception for suspect classifications that also involve medical con- ditions. But discrimination on the basis of medical conditions is often a proxy for discrimination on the basis of suspect classifica- tions. So excusing discrimination on the basis of a suspect class merely because it also involves medical conditions allows laws that discriminate on the basis of a suspected classification to avoid the heightened scrutiny they deserve. And fourth, Geduldig’s logic improperly invites courts to consider, at step one, whether a law is justified when they should be assessing only whether a law classifies on the basis of a suspect classification. That undermines the courts’ ability to engage in meaningful scrutiny at step two. I explain each problem below. A. Geduldig is illogically reasoned under our discrimination jurisprudence. First, despite Geduldig’s holding, it’s common sense that a program that excludes coverage for female-only medical condi- tions, but not any male-only ones, commits sex discrimination. That remains true even if that program discriminates on the basis of a condition not all females endure. Many of our classic antidiscrimination cases bear this out. For example, not all women wished or tried to attend the USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 34 of 108

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prestigious Virginia Military Institute (“VMI”) when just 347 women inquired into attending in 1988 and 1989. See Virginia, 518 U.S. at 523. Yet even in the Equal Protection Clause context, the Supreme Court understood and held that VMI’s program discrim- inated against women because the school refused to consider women for admission because they were women. See generally id. It made no difference that not every woman wanted or had the physical fitness to attend VMI. For purposes of finding a sex classi- fication under the Equal Protection Clause, it was enough that VMI refused to consider the women who did wish to attend and were fit enough to do so, simply because they were women. But under Geduldig’s logic, women fall into the categories of those who wish to attend VMI and those who don’t. So Geduldig would incorrectly conclude that VMI did not discriminate against women under the Equal Protection Clause. Or consider an example Justice Sotomayor raised in Skrmetti. As she explained, “Geduldig’s reasoning may well suggest that a law depriving all individuals who ‘have ever, or may someday, men- struate’ of access to health insurance would be sex neutral merely because not all women menstruate.” 145 S. Ct. at 1880 (So- tomayor, J., dissenting). Indeed, Geduldig’s logic does demand that conclusion. Menstruation, like pregnancy, is a condition that not all females experience. But obviously, a classification on the basis of menstruation classifies by sex. It discriminates against women because only fe- males have ever, or may someday, menstruate. So though such a USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 35 of 108

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law doesn’t mention females expressly, it excludes most females— and no males—from healthcare coverage. That is a sex classifica- tion, whether or not the law expressly refers to men and women. After all, a discriminatory law can’t skirt antidiscrimination law simply by clever drafting that avoids employing express prohibited- class classification in its description. See id. at 1831 (majority opin- ion) (“Of course, a State may not circumvent the Equal Protection Clause by writing in abstract terms.”). Nor does it matter that not all women have ever menstru- ated or will menstruate. That is, it makes no difference that, as in Geduldig, women fall on both sides of the line that the challenged law draws. The law still classifies by sex. Cf. Loving v. Virginia, 388 U.S. 1, 8 (1967) (“The mere fact of equal application does not mean that our analysis of these statutes should follow the approach we have taken in cases involving no racial discrimination . . . .”). The same is true even though the hypothetical law classifies by a phys- ical condition. When a law classifies by a characteristic or condi- tion that is inherently, solely, and overwhelmingly experienced by or connected with only one sex, the law classifies by sex just as surely as if it employed the term “women” or “men.” The rest of antidiscrimination law requires this conclusion. Indeed, if nothing counted as discrimination unless it happened to every member of a protected class, we couldn’t have facial discrim- ination claims. That some members of a protected group don’t suffer under a facially discriminatory policy doesn’t mean the USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 36 of 108

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policy’s not facially discriminatory; it means only that the policy hasn’t yet been applied against that person. Consider a government employer that has a “Dress Code and Appearance” policy. This hypothetical policy requires employ- ees to maintain a “professional” appearance at all times. Let’s say the policy prohibits employees from wearing ashes on their fore- heads or donning yarmulkes, but it doesn’t prohibit the wearing of turbans. Now imagine an employee comes into work on Ash Wednesday with ashes on her forehead in the sign of the cross. And another employee wears a yarmulke to the office. The em- ployer writes them up. Has the employer’s policy discriminated against these workers because they’re Catholic and Jewish, respec- tively? On Geduldig’s reasoning, the answer is no. Not all Catholics attend mass on Ash Wednesday and receive ashes on their fore- heads, and not all Jews wear yarmulkes—just as not all women are pregnant or have menstruated. No matter that everybody (for the most part) who receives ashes on their forehead is Catholic, who wears a yarmulke is Jewish, and who is pregnant or menstruates was assigned female at birth. Geduldig’s logic draws lines by requiring every member of a protected class to actually participate in the prohibited conduct or endure the targeted condition for the challenged program. But that’s not how antidiscrimination law works—even under non- Geduldig Equal Protection Clause jurisprudence. As I’ve noted, in USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 37 of 108

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United States v. Virginia, not every woman wanted or was otherwise eligible to attend VMI. VMI’s admission policy had no effect on the majority of women’s lives. But the fact that the overwhelming percentage of women (far more than who become pregnant) didn’t suffer any harm from VMI’s policy didn’t make the policy any less of a classification by sex or discriminatory against women. Similarly, the law at issue in Loving v. Virginia violated the Equal Protection Clause because it banned interracial marriages— even though not every member of any given racial group was in (or sought out) an interracial marriage. See 388 U.S. at 11. It didn’t matter that people of any particular racial group existed on both sides of the line, with some of them in interracial relationships and some not. 11 So just because every Catholic doesn’t wear ashes on Ash Wednesday doesn’t mean a policy targeting ash-wearers doesn’t classify by Catholicism. Nor does the fact that not every Jew wears a yarmulke mean a policy targeting yarmulke-wearers doesn’t dis- criminate against Jews. Similarly, not every woman gets pregnant or menstruates; but that doesn’t mean that laws targeting those conditions wouldn’t classify by sex and discriminate against women. Policies that target a protected class in this way—harming

11 True, as Skrmetti noted, Virginia’s antimiscegenation law included an ex-

press “race-based classification,” anyway. See 145 S. Ct. at 1831. But again, antidiscrimination law does not turn on magic words or express classifications because, “[o]f course, a State may not circumvent the Equal Protection Clause by writing in abstract terms.” See id. USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 38 of 108

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only people in that class, though not harming all people in that class—can still be discriminatory. In short, Geduldig’s reasoning is at war with our antidiscrim- ination law. Indeed, Congress has recognized Geduldig’s logic con- flicts with antidiscrimination law. Two years after the Court issued Geduldig, the Court relied on Geduldig to conclude in General Electric Co. v. Gilbert, 429 U.S 125 (1976), that an employer’s disability-in- surance program that paid nonoccupational benefits but didn’t cover pregnancy-related disabilities didn’t violate Title VII. Id. at 128. The Court explained its decision by assuming “that the Four- teenth Amendment standard of discrimination is coterminous with that applicable to Title VII,” id. at 154 n.6 (J. Brennan, dissenting); see also id. at 412–13, and then applying Geduldig. Two years later, Congress passed the Pregnancy Discrimination Act of 1978 12 and amended Title VII. The Supreme Court told us what this meant for Geduldig— at least, as applied to the Title VII context—in Newport News. To the point, the Court explained that, with the 1978 amendments, Congress adopted the dissenters’ position in Geduldig. See 462 U.S. at 683–84. So a program need not cover one group as a whole, and not cover another group as a whole, to count as discriminatory. See id. at 683. Differences in coverage of a smaller “magnitude” can

12 Pub. L. No. 95-555, § 1, 92 Stat. 2076, 2076 (codified at 42 U.S.C. § 2000e(k)

(2012)). USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 39 of 108

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violate Title VII. 13 Id. As a result, the Court found that the health plan at issue in Newport News discriminated on the basis of sex be- cause it “unlawfully [gave] married male employees a benefit pack- age for their dependents that is less inclusive than the dependency coverage provided to married female employees.” Id. at 684. Not only that, but the Court noted that, through its amend- ments to Title VII, Congress had “made clear that, for all Title VII purposes, discrimination based on a woman’s pregnancy is, on its face, discrimination because of her sex.” Id. In other words, classi- fying on the basis of a physical or medical condition that is unique to one sex is the same thing as classifying on the basis of sex. Newport News’s reasoning seemingly inflicts a death blow on Geduldig’s logic for two reasons. First, Geduldig’s logic effectively requires that a program burden all members of a protected class to “classify” on a protected basis. The health plan in Newport News, of course, didn’t. And second, Geduldig’s logic excuses classification on the basis of sex if it can be recharacterized on the basis of a phys- ical or medical condition—even if only one sex experiences that condition.

13 For example, the Court explained, “a plan that provided complete hospital-

ization coverage for the spouses of female employees but did not cover spouses of male employees when they had broken bones would violate Title VII by discriminating against male employees.” Id. That’s so even though some “diagnoses” of male employees’ spouses (namely, those that don’t in- volve broken bones) remain covered. The point was that this plan discrimi- nated in part on the basis of sex. See id. USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 40 of 108

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We don’t have to wonder whether the Newport News Court knew what it was doing when it flatly rejected Geduldig’s reasoning. Rather, the Court told us that Congress “unambiguously” rejected “both the holding and the reasoning” of Geduldig when it passed the Pregnancy Discrimination Act of 1978. Id. at 678 (emphasis added). In fact, the Court emphasized, it understood that Congress did not “limit[] the scope of the act to the specific problem that motivated its enactment.” Id. at 679. Put simply, Geduldig no more for Title VII jurisprudence. And it’s not just Newport News. The Supreme Court has taken the same tack in several of its other post-Geduldig Title VII decisions, too. For example, the Supreme Court found that a pol- icy was facially discriminatory when it barred all fertile women (but not infertile women) from jobs involving lead exposure in UAW v. Johnson Controls, Inc., 499 U.S. 187, 190–91, 198–98 (1991). In neither Johnson Controls nor Newport News did it matter that peo- ple within the suspect class stood on both sides of the line. See also Connecticut v. Teal, 457 U.S. 440, 455 (1982) (“It is clear that Con- gress [in Title VII] never intended to give an employer license to discriminate against some employees on the basis of race or sex merely because he favorably treats other members of the employ- ees’ group. . . . Title VII does not permit the victim of a facially discriminatory policy to be told that he has not been wronged be- cause other persons of his or her race or sex were hired.”). At bottom, it’s simply factually incorrect to say that a law or a program that targets the conditions or characteristics of only USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 41 of 108

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members of a protected class does not classify by protected class, even if it doesn’t affect each and every member of that protected class. Congress has already rejected that reasoning, and until re- cently, the Supreme Court had, too. B. Geduldig’s logic embraces, rather than rectifies, historical sex-stereotyping discrimination. Second, Geduldig’s logic effectively embraces a historic sex- discrimination rationale: that the fact that women can become pregnant somehow justifies treating them less favorably. We see this in the example of Geduldig itself. Shortly after the Court issued its opinion, Professor Katharine T. Bartlett recognized this irony: “That women may and do become pregnant is the most significant single factor used to justify the countless laws and practices that have disadvantaged women for centuries.” Katharine T. Bartlett, Comment, Pregnancy and the Constitution: The Uniqueness Trap, 62 CALIF. L. REV. 1532, 1532 (1974). Justice Ginsburg recognized this as well, as our anti- discrimination jurisprudence continued to develop. See Coleman v. Ct. of Appeals of Md., 566 U.S. 30, 56 (2012) (Ginsburg, J., dissenting) (stating that because “pregnancy provided a central justification for . . . historic discrimination against women,” Geduldig “was egre- giously wrong to declare that discrimination on the basis of preg- nancy is not discrimination on the basis of sex” (emphasis added)). Pregnancy has long been leveraged as a means of differenti- ating between men and women in employment, disability benefits, USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 42 of 108

22 ROSENBAUM, J., Concurring in the Judgment 22-13626

and more.14 Indeed, employers have weaponized pregnancy as an excuse to discriminate against women for years—and employers’ views on pregnancy have been “inextricably intertwined with [their] ‘stereotypical views about women’s commitment to work and their value as employees.’” Id. (citation omitted). In finding that California’s disability-insurance program wasn’t sex-based, the Geduldig Court ignored this history and, in effect, endorsed the United States’s historically ingrained practice of discriminating against women on the basis of pregnancy. C. Geduldig illogically endorses laws that classify on the ba- sis of a suspect classification just because they also classify by medical condition. Third, Geduldig’s reasoning is illogical because it gives a free pass to laws that discriminate on the basis of suspect classifications, if they also involve medical classifications. For instance, in Skrmetti, the Court described Geduldig as standing for the proposition that a law doesn’t classify by sex “by regulating a medical procedure that only one sex can undergo unless the regulation is a mere pretext for invidious sex discrimination.” See 145 S. Ct. at 1833. But that

14 See, e.g., Reva B. Siegel, Employment Equality Under the Pregnancy Discrimina-

tion Act of 1978, 94 YALE L.J. 929, 942 & n.63 (1985) (observing that pregnancy is “traditionally believed to render women unfit for employment” and collect- ing sources); Maya Manian, Commentary on Geduldig v. Aiello, in FEMINIST JUDGMENTS: REWRITTEN OPINIONS OF THE UNITED STATES SUPREME COURT 185, 187 (Kathryn M. Stanchi, Linda L. Berger & Bridget J. Crawford eds., 2016) (arguing that the Geduldig majority ignored “the long history of women’s subordination based on their capacity for pregnancy”). USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 43 of 108

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approach conflates the first and second steps of antidiscrimination analysis. First, we have to ask whether the law classifies by sex. Only then can we ask, at step two, why the law classifies by sex— whether for a legitimate reason or a discriminatory (invidious) one. The regulation’s justification doesn’t affect whether the law classifies by sex in the first place, though. A law justified on grounds having to do with “medical classifications” can still classify on the basis of sex, too, as I’ll get to shortly. The Skrmetti Court also distinguished Justice Sotomayor’s hypothetical law that classifies on the basis of menstruation from Geduldig by saying that the hypothetical law “does not regulate a class of treatments or conditions. Rather, it regulates a class of per- sons identified on the basis of a specified characteristic.” Id. at 1834 n.3. Yet the fact that a law regulates medical treatments or con- ditions doesn’t necessarily insulate it logically or factually from also classifying by sex. Imagine, for instance, that besides excluding coverage for pregnancy-related disabilities, the California disability insurance plan at issue in Geduldig also excluded coverage for disa- bilities relating to uterine cancer, polycystic ovary syndrome, uter- ine fibroids, ovarian cancer, endometriosis, cervical cancer, and Turner syndrome—all medical conditions that affect only females. But at the same time, the law provided coverage for disabilities aris- ing from all other medical conditions, including prostate issues, erectile dysfunction, testicular cancer, and other conditions that only males can get. So the law denied coverage for several (and USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 44 of 108

24 ROSENBAUM, J., Concurring in the Judgment 22-13626

only) disabilities arising from medical conditions that only females can suffer, while males enjoyed coverage for disabilities arising from any medical conditions they might have, including those that only males can present with. That’s a classification on the basis of sex, even if the law also classifies on the basis of medical condi- tion. 15 Or take another example. Imagine a healthcare plan that precludes treatment for or relating to circumcised penises. Cir- cumcision is a medical condition. It also happens to be a medical condition that is religiously mandated for many in Judaism and Is- lam, so it is widely shared by Jews and Muslims in comparison to members of other religions (or no religion). But just because the plan classifies by medical condition doesn’t mean that it doesn’t also classify by religion. For all the reasons I’ve already discussed in this opinion, laws like these certainly classify by suspect classification, even though they also classify by medical condition. Cf. Bostock, 590 U.S. at 667 (“Sex wasn’t the only factor, or maybe even the main factor, but it was one but-for cause—and that was enough.”). And Geduldig’s failure to recognize this fact caused it to incorrectly

15 As we’ll get to soon enough, Bostock tells us that we must ask whether the

challenged program or policy classifies on the basis of sex at the level of the individual. And so we must do that analysis at the appropriate level of gener- ality. Of course, a program that discriminates against an individual female can also, in practice, discriminate at a higher level of generalization—that is to say, against all or most women, as these examples show. USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 45 of 108

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conclude that the law there didn’t classify on a suspect-classifica- tion basis. D. Geduldig improperly collapses the discrete inquiries under the first and second steps of the discrimination analysis, which results in applying the wrong level of scrutiny at step two. And that brings me to the fourth reason Geduldig is illogical: Geduldig allowed the second part of the discrimination analysis— review of the law’s reasons and its tailoring—to leach into and de- termine the first part—whether the law classifies by protected class. In particular, the Court reasoned that because covering disabilities related to pregnancy would increase the cost of California’s pro- gram, the program regulated only by medical condition and not by sex. But consideration of the cost—that is, the reason why Califor- nia decided to write its disability-insurance program the way that it did—tells us nothing about whether the law classifies by sex. Ra- ther, that consideration goes to only the second part of the discrim- ination analysis: whether the state had a legitimate reason for using a sex-based classification and whether the law is appropriately tai- lored under the circumstances. By importing the reason for the state’s classification decision into the determination of whether the classification classifies on a protected basis, Geduldig collapses the discrimination analysis. And that means that Geduldig allows laws that classify on a protected- class basis—that is, laws that classify in a way that the Constitution considers especially suspect—to escape application of the correct USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 46 of 108

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(and more exacting) level of scrutiny at the second step of the dis- crimination analysis. As a result, laws that are unconstitutional wrongly survive review. III. Skrmetti misguidedly applied Geduldig’s reasoning when it interpreted Bostock, which defines Title VII’s methodology for determining whether a law discrim- inates on the basis of a protected class. This section explains why Skrmetti binds us to uphold Hou- ston County’s healthcare plan. I conclude Skrmetti requires this re- sult, even though Lange challenges the plan under Title VII, not the Equal Protection Clause, which Skrmetti was based on. Skrmetti does so because it imports Geduldig’s reasoning into Title VII anal- ysis in cases like this one, even though both Congress and the Su- preme Court previously have told us that Title VII rejects Geduldig’s reasoning. Still, because the Court chose that path, I’m obligated to follow it today. A. Skrmetti requires us to uphold Houston County’s healthcare plan. I begin by explaining why Skrmetti requires us to uphold Houston County’s healthcare plan. As a reminder, the law at issue in Skrmetti prohibited the administration of gender-affirming drugs to minors whose birth-assigned sex did not match their gender identity. See 145 S. Ct. at 1826–27. The Court concluded that the law didn’t classify on the basis of sex or transgender status. Id. at 1829–34. USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 47 of 108

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In reaching that conclusion, the Court anchored its analysis in Geduldig’s reasoning. See id. at 1833. It said that the law there “divide[d] minors into two groups: those who might seek puberty blockers or hormones to treat the excluded diagnoses, and those who might seek puberty blockers or hormones to treat other con- ditions.” Id. But, the Court continued, transgender individuals fall into both groups. Id. Then the Court compared its analysis of the law to Geduldig’s analysis of the insurance plan at issue there. It reasoned, “[A]lthough only transgender individuals seek treatment for gender dysphoria, gender identity disorder, and gender incon- gruence—just as only biological women can become pregnant— there is a ‘lack of identity’ between transgender status and the ex- cluded medical diagnoses.” Id. After applying Geduldig to conclude that the Skrmetti law didn’t classify on a suspect-classification basis, the Court devoted a separate section of its opinion to responding to arguments that Bos- tock, a Title VII case, required a different answer. See id. at 1834– 35. The Court concluded Bostock did not. Id. It began by assuming without deciding that Bostock’s analysis could apply in the Equal Protection Clause context. Id. at 1834. Next, the Court said it was applying Bostock. See id. The Court noted that Bostock “reasoned that Title VII’s ‘be- cause of’ test incorporates the traditional but-for causation stand- ard, which ‘directs us to change one thing at a time and see if the outcome changes. If it does, we have found a but-for cause.’” Id. (quoting Bostock, 590 U.S. at 656). To apply this test, the Court used USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 48 of 108

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the example of a transgender boy who seeks testosterone to treat his gender dysphoria—something the law prohibited a healthcare provider from administering to him. Id. The Court observed that changing his biological sex from female to male “would still not permit him the hormones he seeks because he would lack a quali- fying diagnosis for the testosterone . . . .” Id. Yet “if he had such a diagnosis,” the Court went on, “he could obtain the testosterone regardless of his sex or transgender status.” Id. Based on this dis- cussion, the Court concluded that, “[u]nder the reasoning of Bos- tock, neither [the transgender boy’s] sex nor his transgender status is the but-for cause of his inability to obtain testosterone.” Id. As for the possibility that sex or transgender status might be one of multiple but-for causes, the Court ruled that out. See id. at 1835. To do so, the Court used an example of a “girl with un- wanted facial hair inconsistent with her sex,” and a diagnosis of hir- sutism (male-pattern hair growth). Id. The Court explained that a healthcare provider could prescribe her puberty blockers or hor- mones to make her appearance more consistent with her birth-as- signed gender if she had a diagnosis of male-pattern hair growth. Id. But if she were a boy, the Court said, that would “not automat- ically change the operation of [the Skrmetti law].” Id. To show why, the Court pointed to two different medical diagnoses: gender dysphoria and precocious puberty. Id. Under the law, a boy couldn’t get puberty blockers if his diagnosis was gender dysphoria instead of hirsutism, but he could if it was precocious puberty. Id. So, the Court concluded, “sex is simply not a but-for cause of [the Skrmetti law’s] operation.” Id. USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 49 of 108

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Under Skrmetti’s version of Bostock’s reasoning, we could consider the example of a birth-assigned male with undesired en- larged breast tissue inconsistent with their sex, who was diagnosed with gynecomastia. That person could receive a breast reduction or mastectomy under Houston County’s healthcare plan. But if they were a birth-assigned female with unwanted breast tissue in- consistent with their gender identity, that would “not automati- cally change the operation of [the healthcare plan].” Skrmetti, 145 S. Ct. at 1835. Rather, that birth-assigned female could get a mas- tectomy if they had breast cancer that warranted it. But they couldn’t if they wanted the mastectomy to confirm their gender identity. I just don’t see a way to distinguish Skrmetti’s application of Bostock from the healthcare plan at issue here. And because the Court had to undertake its Bostock analysis to respond to arguments that Bostock required a different outcome than the Court reached under Geduldig, I think we are bound by the Court’s Bostock appli- cation in Skrmetti. In fact, had the Court determined in Skrmetti that Bostock required a different answer than Geduldig did, the Court would have had to strike down the Skrmetti law, unless it also concluded that Bostock’s analysis didn’t govern Equal Protec- tion Clause cases. But of course, Bostock’s analysis does control Ti- tle VII cases. To be sure, Skrmetti’s conclusion that Bostock demands the same answer as Geduldig seems to conflict with Newport News’s treatment of Geduldig’s logic in the Title VII context. But because USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 50 of 108

30 ROSENBAUM, J., Concurring in the Judgment 22-13626

of Skrmetti, a conflict in Title VII law now exists between Newport News’s reasoning and Bostock’s, when it comes to the specific area of transgender individuals and medical diagnoses. When, as here, two binding precedents that are relevant to a dispute before us con- flict, we must follow the one that “has direct application” to the case. See, e.g., Agostini v. Felton, 521 U.S. 203, 237 (1997) (“We reaf- firm that ‘[i]f a precedent of this Court has direct application in a case, yet appears to rest on reasons rejected in some other line of decisions, the Court of Appeals should follow the case which di- rectly controls, leaving to this Court the prerogative of overrul- ing its own decisions.’” (citation omitted and emphasis added)). I don’t think I can say Newport News “has direct application” to this case, compared to Bostock. Newport News involved preg- nancy-related discrimination, and the Court considered it under the Pregnancy Discrimination Act. Bostock, in contrast, does di- rectly apply here: it specifically involved and analyzed claims of sex-discrimination on the basis of transgender status. And the Court in Skrmetti changed how we do the Bostock test, at least in the specific context of analyzing laws involving transgender indi- viduals and medical diagnoses. Though I think this was misguided, it also binds us in this case. B. Skrmetti incorrectly construed Bostock. Most respectfully, it seems to me that Skrmetti departed from what Bostock demands because Skrmetti relied on Geduldig. Skrmetti inadvertently imported Geduldig’s reasoning—at least USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 51 of 108

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when it comes to challenges that an employer discriminated on the basis of gender-dysphoria treatments—into the Title VII context. To explain, we must zoom in on Bostock. Bostock’s founda- tional principle teaches that to discern sex discrimination under Ti- tle VII, “our focus should be on individuals, not groups.” Bostock, 590 U.S. at 658. And that principle drove the outcome in Bostock. There, the Court considered, among other things, whether an individual gay man suffers sex discrimination when his em- ployer discriminates against him because he’s attracted to males. See Bostock, 590 U.S. at 653. When we change the employee’s sex, they become a female attracted to males, and their employer takes no issue. So Bostock recognizes that the employer’s change in ac- tion happens “because of” the employee’s sex. And under Bostock, our individual male suffered sex discrimination. See id. at 660. But something else happens when we apply this test; of ne- cessity, “[a]long the way, we change his sexual orientation too (from homosexual to heterosexual).” Id. at 671. The gay “man” is now not only not a “man” but also no longer “gay.” Rather, this hypothetical person is now a “heterosexual woman” because this person is a woman attracted to men. We previously labeled this individual a gay man. But when we change his sex, a new label definitionally applies—heterosexual woman. We can’t change the gay man’s sex without changing the more general corresponding label that describes him—“homosexuality” is not an accurate de- scriptor anymore, for the hypothetical attracted-to-men female comparator. USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 52 of 108

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To put it simply, when we describe this prospective plaintiff at the individual level, we’d say he is (1) a man, who is (2) attracted to men, and therefore (3) he’s also gay. Bostock counsels us to change just one thing, so all we change is his sex—and therefore that makes the hypothetical comparator (now a woman attracted to men) straight. So the Bostock test changes a male attracted to males into a female attracted to males, even though doing so makes it no longer accurate to call our individual “gay.” The Court could have fashioned a different test in Bostock. It could have instructed us that to change the sex of a gay male, keeping all else constant, we change him into a gay female. That way, the general demographic description of the person would stay constant. But the Court expressly rejected that approach. See id. Why? Because a gay female is not the female version of the gay individual man. Besides being female, the gay female has a sec- ond trait the gay male doesn’t: she’s attracted to females, but he’s attracted to males. So her experience doesn’t describe our prospec- tive plaintiff as an individual nor inform whether he has been dis- criminated against as an individual. All it does is preserve the cor- rect general, group-level descriptor—calling the comparator “gay.” The more general “gay” label takes into account two more specific things, of course—that our plaintiff is a man, and that he’s attracted to men. So if we tried to define the comparator on the basis of retaining this higher-level characteristic of homosexuality, we’d ef- fectively take away what makes our prospective plaintiff who he is, as an individual—someone attracted to men. Put differently, we’d USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 53 of 108

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be changing two things about him as an individual, just to fit him into this bigger “group” of same-sex-attracted people. But Title VII doesn’t care about group experience—it cares that no individual bears the brunt of sex discrimination in their unique experience. In trying to grow a forest, the test Bostock re- jected misses the individual trees. But the Bostock test doesn’t; it instructs us that when we change the sex of our person experienc- ing sex discrimination, we need to describe him with sufficient spec- ificity to capture his individualistic experience—changing only one thing at a time. We can’t just change a generic gay male into a gay female. We need to describe the gay male specifically—as a man who’s attracted to men—and then change his sex. To summarize, Bostock creates its own new three-step test. First, we describe the person alleging discrimination at the correct level of specificity. At step one, we swap out the label “gay” from a gay male and describe him in greater detail—he’s a male attracted to males. Then, at step two, we identify his comparator by chang- ing his sex, so he becomes a female attracted to males. Now, at step three, we can redescribe the comparator with any general la- bels that might help us understand who this new person is. And it turns out, our new person’s not a gay female but a heterosexual female. We’ve found the person of the opposite sex whose experi- ence most closely mirrors him as an individual. The level of generality at which we describe the person fac- ing discrimination (i.e., the more general descriptor, “a gay man,” or the more specific one, “a male attracted to males”), changes how USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 54 of 108

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we do the analysis. And we need to adopt the level of specificity that Bostock itself did. Faithfully applying Bostock’s test to Skrmetti’s facts yields an answer opposite to the one that Skrmetti reached. Let’s consider Skrmetti’s example of a male who has unwanted facial hair. Zoom- ing out to a higher level of generality, we give him the general label of a male seeking gender-dysphoria treatment. But we can’t jump to step two and change his sex, without doing step one where we first describe him with sufficient specificity. A male seeking gen- der-dysphoria treatment doesn’t become a female seeking gender- dysphoria treatment. A female seeking gender-dysphoria treat- ment is a person who needs treatment to develop more masculine features. She isn’t the female version of the male seeking gender- dysphoria treatment, who needs to develop more feminine fea- tures. So at step one, we exchange our individual male’s general label of a male seeking gender-dysphoria treatment and instead de- scribe him more specifically—he’s a male with unwanted facial hair. Then, at step two, we identify his comparator by changing his sex, so he becomes a female with unwanted facial hair. Now, at step three, we can redescribe this comparator using any general labels that might help us understand who this new person is. And it turns out that our new person’s a female with hirsutism, not gen- der dysphoria. We’ve found the person of the opposite sex whose experience most closely mirrors our male as an individual. USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 55 of 108

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As under Bostock, the level of generality at which we describe the person facing discrimination (i.e., the more general descriptor, “a male with gender dysphoria,” or the more specific one, “a male with unwanted facial hair”) changes the outcome of the analysis. And Bostock requires us to adopt that more specific level of gener- ality. Under Bostock, it doesn’t matter that if our individual male’s diagnosis had been precocious puberty, he could’ve received treat- ment as a male. But see Skrmetti, 145 S. Ct. at 1835 (reasoning the opposite). Our hypothetical individual experiencing gender dys- phoria doesn’t have “precocious puberty.” That condition de- scribes a separate individual who is irrelevant to the analysis of this individual with gender dysphoria. The fact that another male doesn’t experience discrimination and can get the treatment our individual seeks doesn’t change that our individual has experienced unlawful discrimination. That’s what Bostock teaches us. Imagine an employer who fires an individual gay male only because that male is married to another male, but the employer would not have fired the male if he remained unmarried. Under Bostock, that employer violates Ti- tle VII just as much as if it fired all gay males because it would have tolerated a female’s marriage to a male. It doesn’t matter that the employer doesn’t fire all gay males because the employer discrim- inated against our individual male on the basis of sex. Cf. Bostock, 590 U.S. at 659 (“It’s no defense for the employer to note that, while he treated that individual woman worse than he would have USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 56 of 108

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treated a man, he gives preferential treatment to female employees overall. The employer is liable for treating this woman worse in part because of her sex.” (emphasis in original)). In the same way, an employer can’t deny employment op- portunities to pregnant women just because it treats non-pregnant women fairly, despite the principles of Geduldig. See Newport News, 462 U.S. at 678. Nor, when we do Bostock’s three steps correctly, will we find the female version of our hypothetical male is a female with facial hair who somehow lacks any medical diagnosis. But see Skrmetti, 145 S. Ct. at 1834 (reasoning that the comparator “would lack a qualifying diagnosis”). That misapplies step three. At step one, we recognize a male seeking gender-dysphoria treatment is a male with male-pattern facial hair he seeks to remove to make his face more feminine. We then do step two, and he becomes a female with male-pattern facial hair she seeks to remove to make her face more feminine. And now, we do step three and redescribe her at the general level. She’s not a person with no medical diagnosis, for which she needs treatment. The person we have described specifi- cally would be described more generally at step three as a woman with hirsutism. That’s the diagnosis she’d walk out of the doctor’s office with. But that’s not something that we’ve changed; that’s a descriptor that’s inherently had to change, when we change just her sex and nothing else. Cf. Bostock, 590 U.S. at 671 (“Along the way, we change his sexual orientation too (from homosexual to hetero- sexual).”). And her employer covers treatment for her condition of USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 57 of 108

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hirsutism. So the employer denied treatment to our original indi- vidual male only because he was male. Bostock demands we drop the more general labels (i.e., someone who meets the definition of “gay,” or whose condition means the definition of “gender dysphoria”) at step one, so that we can capture the individual experience (i.e., attending to the specifi- cally applicable component parts of those definitions). And when we find, as here, that the female parallel to the individual male with gender dysphoria would have access to the treatment the original male wants, that individual male has experienced sex discrimina- tion. 16 The employer’s actions towards any person other than the

16 The fact that the plan at issue here prohibits coverage for “sex-change rever-

sals” doesn’t show that an individual male seeking a sex-change operation hasn’t suffered sex discrimination. We need to be careful to accurately con- duct Bostock’s three steps. Our individual male seeking a sex-change operation is a male seeking the construction of a vagina. This person has no history of having undergone a procedure to medically construct a penis. So the female version of this individual male, found at step two, also doesn’t have this history of having medically constructed a penis. Rather, the comparator is a female seeking the construction of a vagina with no history of having a medically con- structed penis. Otherwise, the comparator is not the female version of the prospective plaintiff. So at step three, it would be inaccurate to describe the comparator as a female seeking a “sex-change reversal.” The comparator’s sex has never been changed. A female seeking a “sex-change reversal” describes a wholly different person from the female parallel to our individual male. And that female’s experience is irrelevant to whether our individual has experi- enced sex discrimination. An eagle-eyed reader might point out that at step one, we could describe our individual male as a male with a penis seeking the construction of a vagina. Then at step two, we change that person to a female with a penis seeking the USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 58 of 108

38 ROSENBAUM, J., Concurring in the Judgment 22-13626

exact parallel female individual with hirsutism are irrelevant. No ifs, ands, or buts: if an employer treats an individual differently than it would if his sex were different, it has violated Title VII.

construction of a vagina. And at step three, this new person seems like a fe- male seeking a “sex-change reversal.” But that’s the result of two subtle errors at steps two and three. First, at step two, when we change our individual male to a female, we have to actually change this person into a female—change their birth-assigned sex. That means we can’t retain the genitalia this person had at birth. So the female comparator doesn’t have a penis from birth. Otherwise, for example in Bostock itself, the court should have described a “gay man” as a male with a penis with which he has sexual relations with males, who, at step two becomes a female with a penis with which she has sexual relations with males. And at step three, we would be left with a comparator who is not female but intersex. (Though Bostock’s implications for intersex individuals are outside the scope of this opin- ion, others have thoughtfully considered the issue. See, e.g., Sam Parry, Sex Trait Discrimination: Intersex People and Title VII After Bostock v. Clayton County, 97 WASH. L. REV. 1149, 1150 (2022) (observing that “[b]ecause current Title VII jurisprudence assumes there are only two sexes, the legal status of intersex people remains in limbo”)). And even if we could carry over our individual male’s penis in step two, it would be inaccurate, at step three, to describe this new female with a penis as a female seeking a “sex-change reversal.” That’s because this seemingly inter- sex person would have had their penis at birth as our original individual male did—it would not be the result of medical construction. So at step three, we could not describe this person as seeking a “sex-change reversal.” This indi- vidual seeks no “reversal” of anything. At bottom, a female seeking a “sex- change reversal” is just not a relevant comparator for a male seeking a “sex- change” operation. USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 59 of 108

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C. Skrmetti incorrectly imports Geduldig’s reasoning into Title VII cases involving transgender individuals seeking medical treatment. That was the law until Skrmetti. But in Skrmetti, the Court determined that a male with gender dysphoria exacerbated by their facial hair growth may be denied care when a female with hir- sutism is not because males with “precocious puberty” also receive treatment. See Skrmetti, 145 S. Ct. at 1835. That is—sex discrimi- nation against an individual with gender dysphoria is permissible because other males don’t experience gender dysphoria.17 Skrmetti justifies discrimination against an individual because other mem- bers of the group he is a part of are spared. That’s exactly counter to the principles of Bostock. Indeed, if Bostock were decided under Skrmetti’s interpreta- tion of Bostock, Bostock would have come out differently. The Court would have compared the male and female counterpart at the more general level of the “gay” label descriptor (instead of the

17 It’s irrelevant under Bostock, that if we take a female with hirsutism, and turn

that person into a male, they might be a male with either “gender dysphoria” or “precocious puberty.” But see Skrmetti, 145 S. Ct. at 1835. That might in- form an analysis of whether an individual with hirsutism experiences sex dis- crimination. But it says nothing, under the Bostock test, about whether a dif- ferent individual male with gender dysphoria (due to excessive facial hair) ex- periences sex discrimination. To figure out whether that person experienced sex discrimination, we change that person’s sex, not the sex of the female with hirsutism. And when we change the sex of our male with excessive facial hair, who therefore has gender dysphoria, we always end up with a female with excessive facial hair, who therefore has hirsutism. USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 60 of 108

40 ROSENBAUM, J., Concurring in the Judgment 22-13626

individual level of “attracted to men”) and found that the employer treated both the male and female employees the same way, so it didn’t discriminate on the basis of sex. See Bostock, 590 U.S. at 660. “Why are these” cases involving gender-dysphoria treatment “different from all the rest? Title VII’s text can offer no answer.” Id. at 673. Geduldig gave the Court the answer. It teaches that medical- related claims are different. And discrimination against individuals on the basis of sex can be justified for certain individuals with a medical condition. With Geduldig as its scalpel, Skrmetti performed surgery on Bostock and incorrectly carved out bans on treatment for gender dysphoria from Title VII’s protections. As I’ve explained, though, Congress rejected Geduldig’s rea- soning for Title VII. That is, Congress amended Title VII to ban Geduldig’s logic. So if I weren’t bound by Skrmetti, I’d follow my pre-Skrmetti understanding of Bostock and what I take to be the les- sons of Congress’s amendment of Title VII. So I’d recognize that a policy that bars gender-dysphoria treatment is a sex-based classifi- cation. But I am an inferior-court judge duty bound to follow what I understand Supreme Court precedent to require. And on my reading, the Court went the opposite way in Skrmetti. That con- stricts me here. IV. Conclusion In 1976, the Supreme Court in Craig expressly articulated, for the first time, the intermediate-scrutiny framework for sex- based discrimination claims under the Equal Protection Clause. See USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 61 of 108

22-13626 ROSENBAUM, J., Concurring in the Judgment 41

429 U.S. at 197. Indeed, Craig represented a “compromise on the standard of review to be used in sex discrimination cases,” see Ken- neth L. Karst, The Supreme Court, 1976 Term—Foreword: Equal Citi- zenship Under the Fourteenth Amendment, 91 HARV. L. REV. 1, 54 (1977), following earlier debates on the Court, see, e.g., Geduldig, 417 U.S. at 498 (Brennan, J., dissenting).18 Two years before any of that happened, the Court issued Geduldig. Given that the Court hadn’t yet developed its modern framework for analyzing sex-discrimination claims at that time, it’s especially curious to rely on Geduldig today. Indeed, Geduldig con- flicts with modern Equal Protection jurisprudence because the Su- preme Court issued Geduldig before it developed that jurispru- dence. And the Supreme Court itself has previously recognized that Congress amended Title VII because it rejected Geduldig’s rea- soning. That history may be part of why the Supreme Court itself hasn’t relied on Geduldig much over the last half-century. See, e.g., Coleman, 566 U.S. at 60 n.6 (Ginsburg, J., dissenting) (noting that “the plurality d[id] not cite or discuss Geduldig v. Aiello, perhaps

18 Though “[t]he ‘modern’ era [in considering sex-discrimination claims] began

with Reed v. Reed, 404 U.S. 71 (1971),” Craig represented the “compromise” describing the Court’s modern intermediate standard for these kinds of claims. See Karst, supra at 54 & n.297. For more on the history of the Court’s then- developing standard for sex-discrimination claims brought under the Equal Protection Clause, see Gerald Gunther, The Supreme Court, 1971 Term—Fore- word: In Search of Evolving Doctrine on a Changing Court: A Model for a New Equal Protection, 86 HARV. L. REV. 1, 29–30 (1972); see also Law, supra, at 987–88. USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 62 of 108

42 ROSENBAUM, J., Concurring in the Judgment 22-13626

embarrassed by that opinion’s widely criticized conclusion that dis- crimination based on pregnancy does not involve ‘discrimination based upon gender as such’” (internal citations omitted)). 19 In sum, it’s understandable why the Supreme Court didn’t rely on Geduldig for many years. Geduldig’s reasoning is illogical and fatally flawed. So the Court was right to banish it. Because Skrmetti is based on Geduldig, whose application both Congress and the Court have emphatically rejected in the Title VII context (and, until Skrmetti, seemingly altogether), I respectfully urge the Su- preme Court to reconsider its continued reliance on Geduldig’s rea- soning.

19 In fact, before Skrmetti, the Court had expressly resurrected Geduldig’s rea-

soning only twice. See Bray, 506 U.S. at 271; Dobbs v. Jackson Women’s Health Org., 597 U.S. 215, 216 (2022). USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 63 of 108

22-13626 JILL PRYOR, J., Dissenting 1

JILL PRYOR, Circuit Judge, joined by JORDAN, ABUDU, KIDD, and WILSON, Circuit Judges, dissenting: The Houston County employee health insurance plan we consider here excludes coverage for “[d]rugs for sex change sur- gery” and “[s]ervices and supplies for a sex change and/or the re- versal of a sex change.” Doc. 155-1 at 72, 74. 1 Relying on equal pro- tection precedent, the majority opinion holds that these exclusions do not discriminate based on sex or transgender status under Ti- tle VII because the plan merely “draws a line between certain treat- ments, which it covers, and other treatments, which it does not.” Majority Op. at 16. But the Supreme Court definitively held more than four decades ago that such line drawing is impermissible in Title VII cases when the dividing line is a medical condition that impacts employees differently based on sex. See Newport News Ship- building & Dry Dock Co. v. E.E.O.C., 462 U.S. 669, 678 (1983). The law has been settled on that score ever since. Yet today the majority opinion makes the same mistake in its Title VII analysis that was addressed and corrected long ago by Congress and then by the Su- preme Court—it imports equal protection reasoning into a Ti- tle VII case. Because that reasoning has no place in the case before us, I dissent. The line the majority draws here relies on reasoning from equal protection cases. In Geduldig v. Aiello, the Supreme Court held that a state disability insurance program that excluded

1 “Doc.” numbers refer to the district court’s docket entries. USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 64 of 108

2 JILL PRYOR, J., Dissenting 22-13626

coverage for disabilities caused by pregnancy did not amount to sex-based discrimination under the Equal Protection Clause of the Fourteenth Amendment. 417 U.S. 484, 486–87, 494–95 (1974). The Supreme Court reasoned that “[t]he California insurance program does not exclude anyone from benefit eligibility because of gender but merely removes one physical condition—pregnancy—from the list of compensable disabilities.” Id. at 496 n.20. Despite recog- nizing that this exclusion only impacted women, the Court ex- plained that “it does not follow that every legislative classification concerning pregnancy is a sex-based classification.” Id. “The lack of identity between the excluded disability and gender” meant that the program did not classify based on sex. Id. Instead, “[t]he pro- gram divides potential recipients into two groups—pregnant women and nonpregnant persons. While the first group is exclu- sively female, the second includes members of both sexes.” Id. Therefore, the Court concluded that the program classified based on a medical condition rather than sex. Id. But in Title VII cases, this reasoning has been rejected, first by Congress and then by the Supreme Court. After Geduldig, the Supreme Court applied its equal protection reasoning in a Title VII case, holding that exclusion of pregnancy from an employer health insurance plan did not discriminate based on sex because “[t]he [p]lan . . . is nothing more than an insurance package, which covers some risks, but excludes others.” Gen. Elec. Co. v. Gilbert, 429 U.S. 125, 138 (1976) (citing Geduldig, 417 U.S. at 494, 496–97). Congress responded by amending Title VII. It passed the Pregnancy Discrim- ination Act of 1978, including “pregnancy, childbirth, or related USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 65 of 108

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medical conditions” in the definition of discrimination “because of sex.” 42 U.S.C. § 2000e(k). When a Title VII case challenging an employer health insurance plan that excluded coverage for preg- nancy next reached the Supreme Court, the Court recognized that with this amendment Congress “unambiguously expressed its dis- approval of both the holding and the reasoning of the Court in the Gilbert decision.” Newport News, 462 U.S. at 678. The plan at issue covered pregnancy-related conditions for employees but not for spouses of employees. Id. at 683–84. The Supreme Court explained that by providing full medical coverage for the spouses of female employees and medical coverage except for pregnancy-related con- ditions for the spouses of male employees, the plan discriminated based on sex because it “unlawfully [gave] married male employees a benefit package for their dependents that [was] less inclusive than the dependency coverage provided to married female employees.” Id. at 684. Importantly, the Supreme Court did not limit its disapproval of Geduldig’s reasoning to pregnancy. It reasoned that in relying on Geduldig Gilbert misinterpreted Title VII, which “protect[s] all indi- viduals from sex discrimination in employment—including but not limited to pregnant women workers.” Id. at 681 (emphasis in orig- inal). Since Newport News, an employer insurance plan that excludes coverage of a condition based on sex violates Title VII. After en banc oral argument in this case, the Supreme Court decided United States v. Skrmetti, 145 S. Ct. 1816 (2025). The Court considered an equal protection challenge to a Tennessee law that USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 66 of 108

4 JILL PRYOR, J., Dissenting 22-13626

prohibited medical treatments to minors for conditions that impact only transgender individuals. Id. at 1826–27, 1830–31, 1833. Ten- nessee prohibited treatments administered for the purpose of “[e]nabling a minor to identify with, or live as, a purported identity inconsistent with the minor’s sex” or “[t]reating purported discom- fort or distress from a discordance between the minor’s sex and as- serted identity.” Tenn. Code Ann. § 68-33-103(a)(1). The Supreme Court held that this restriction did not discriminate based on sex because it, instead, “restricts which . . . medical treatments are available to minors . . . to treat gender dysphoria, gender identity disorder, or gender incongruence.” Skremetti, 145 S. Ct. at 1830–31. It further held that the restriction of these treatments did not discriminate based on transgender status. Id. at 1833. Relying on Geduldig, the Court concluded that the Tennessee law did “not ex- clude any individual from medical treatments on the basis of transgender status but rather removes one set of diagnoses—gen- der dysphoria, gender identity disorder, and gender incongru- ence—from the range of treatable conditions.” Id. The Supreme Court explained that the pregnancy exclusion in Geduldig did not discriminate based on sex because it divided the employees into two groups, “‘pregnant women and nonpregnant persons,’” and “[b]ecause women fell into both groups, the program did not dis- criminate against women as a class.” Id. (quoting Geduldig, 417 U.S. at 426 n.20). It reasoned that the Tennessee law created a similar nondiscriminatory distinction. “Because only transgender individ- uals seek puberty blockers and hormones for the excluded diagno- ses, the first group includes only transgender individuals; the USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 67 of 108

22-13626 JILL PRYOR, J., Dissenting 5

second group, in contrast, encompasses both transgender and non- transgender individuals.” Id. The Supreme Court thus held that the law prohibiting medical care to treat conditions that impact transgender individuals only did not classify based on transgender status under the Equal Protection Clause. Id. at 1833–34. Today, by importing Skrmetti’s equal protection reasoning into a Title VII case, the majority commits the same error the Su- preme Court did in Gilbert. The majority opinion concludes that the County health plan’s exclusion of medical care related to a “sex change” does not discriminate based on sex or transgender status because it merely “draws a line between certain treatments, which it covers, and other treatments, which it does not.” Majority Op. at 16. This is the exact same reasoning that both Congress and the Supreme Court rejected for Title VII claims. See Gilbert, 429 U.S. at 138 (“The [p]lan . . . is nothing more than an insurance package, which covers some risks, but excludes others.”); see also Newport News, 462 U.S. at 684 (“Although Gilbert concluded that an other- wise inclusive plan that singled out pregnancy-related benefits for exclusion was nondiscriminatory on its face, because only women can become pregnant, Congress has unequivocally rejected that reasoning.”). And yet the majority opinion revives that very rea- soning to conclude that an employer insurance plan excluding cov- erage for medical care that only transgender individuals need does not discriminate based on transgender status or on sex. The majority does so in the face of binding Supreme Court precedent holding that under Title VII the fact that only women USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 68 of 108

6 JILL PRYOR, J., Dissenting 22-13626

can get pregnant makes a pregnancy-based exclusion sex-based and therefore facially discriminatory. See Newport News, 462 U.S. at 684. Likewise, the fact that only transgender individuals can require “sex changes” renders the County’s exclusion transgender-based. Under Title VII “it is impossible to discriminate against a person for being . . . transgender without discriminating against that individ- ual based on sex.” Bostock v. Clayton Cnty., 590 U.S. 644, 660 (2020). And Title VII “protect[s] all individuals from sex discrimination.” Newport News, 462 U.S. at 681. So Supreme Court precedent dic- tates that excluding from coverage healthcare that only transgender individuals can require constitutes sex-based discrimi- nation in violation of Title VII. The fact that the exclusion here ap- plies equally to individuals the majority calls “natal men” who are transgender and to “natal women” who are transgender does not make the exclusion neutral under Newport News. In Skrmetti, the majority said, “[w]e have not yet considered whether Bostock’s reasoning reaches beyond the Title VII context, and we need not do so here.” 145 S. Ct. at 1834. Despite expressly stating that it was not considering or deciding whether Bostock’s reasoning applied to equal protection claims, the majority none- theless observed that Bostock “does not alter our analysis.” Id. But Skrmetti’s discussion of Bostock is utterly devoid of references to Geduldig and its equal protection progeny. See id. Because Skrmetti’s analysis of Bostock implicitly relied on since-rejected reasoning from Geduldig and Gilbert, the Supreme Court has created a tension that only it can resolve. USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 69 of 108

22-13626 JILL PRYOR, J., Dissenting 7

The Skrmetti majority’s discussion of Bostock does not bind us. No Title VII claim was before the Supreme Court. Skrmetti therefore did not and could not decide whether an employer’s in- surance plan that bases coverage of medical treatments on sex or transgender status violates Title VII. Nor did Skrmetti address the use of equal protection precedent in the Title VII context in com- menting on Bostock. Finally, Skrmetti did not acknowledge or dis- cuss Newport News. Although we do not take lightly Supreme Court dicta, we simply are not free to follow it in the face of binding Su- preme Court authority to the contrary. After all, “[t]he Supreme Court has told us, over and over again, to follow any of its decisions that directly applies in a case, even if the reasoning of that decision appears to have been rejected in later decisions and leave to that Court ‘the prerogative of overruling its own decisions.’” Evans v. Sec’y, Fla. Dep’t of Corr., 699 F.3d 1249, 1263 (11th Cir. 2012) (quot- ing Tenet v. Doe, 544 U.S. 1, 10–11 (2005)); see also United States v. Davis, 785 F.3d 498, 521 (11th Cir. 2015) (en banc) (William Pryor, J., concurring) (“As judges of an inferior court, we have no business in anticipating future decisions of the Supreme Court). I believe we are bound by Newport News’s holding that an employer insurance plan that excludes coverage of a condition based on sex violates Ti- tle VII, see 462 U.S. at 684, and Bostock’s unequivocal statement that for Title VII purposes “discrimination based on . . . transgender sta- tus necessarily entails discrimination based on sex.” 590 U.S. at 669. Because the majority relies on analysis that both Congress and the Supreme Court—interpreting Congress’s action—have re- jected for Title VII claims, I respectfully dissent. USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 70 of 108

22-13626 ABUDU, J., Dissenting 1

ABUDU, Circuit Judge, Dissenting: I dissent from the majority opinion because the holding is contrary to Title VII’s plain language, reasonable interpretation, and clear mandate to eradicate sex-based discrimination, in all its forms, in the workplace. See Bostock v. Clayton Cnty., 590 U.S. 644, 674 (2020) (“[W]hen the meaning of the statute’s terms is plain, our job is at an end. The people are entitled to rely on the law as writ- ten, without fearing that courts might disregard its plain terms based on some extratextual consideration.”). For the reasons stated in Judge Wilson’s and Judge Jill Pryor’s dissents, Houston County’s decision to exclude from its employee health insurance plan coverage related to “sex change surgery” is a sex-based form of discrimination and, thus, clearly violates Title VII. As my dissent- ing colleagues discuss, the Supreme Court’s recent decision in an Equal Protection Clause case, United States v. Skrmetti, 145 S. Ct. 1816 (2025), does not alter that legal conclusion.1

1 Justice Thomas saw “no reason to import Bostock’s Title VII analysis into the

Equal Protection Clause.” 145 S. Ct. at 1838 (Thomas, J., concurring). The Bostock Court’s analysis relied on specific terms found “within the context of Title VII,” and the Equal Protection Clause “include[d] none of th[at] lan- guage.” Id. “That such differently worded provisions should mean the same thing is implausible on its face.” Id. (quoting Students for Fair Admissions, Inc. v. President & Fellows of Harvard Coll., 600 U.S. 181, 308 (2023) (Gorsuch, J., concurring)). Accordingly, he noted that “[e]xtending the Bostock framework [to Skrmetti] would depart dramatically from this Court's Equal Protection Clause jurisprudence.” Id. Similarly, we should not extend Skrmetti’s Equal Protection Clause analysis to this Title VII context and stray from established Title VII jurisprudence. USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 71 of 108

2 ABUDU, J. Dissenting 22-13626

I write separately to acknowledge the ongoing cultural war in which this Court, like courts before us, has had to participate. Our role is to ensure that, regardless of religious, political, or other ideologies, the law applies equally to all. The majority’s decision, unfortunately, undermines that goal and sets us up for yet another episode in our Circuit’s legal history where the majority just gets the outcome wrong, and the short- and long-term implications of its flawed decision cannot be ignored. I. The Majority Opinion Directly Conflicts with Bostock For Deputy Anna Lange and millions of transgender peo- ple, 2 gender is not binary. After serving on the Houston County police force for nearly twelve years, Deputy Lange took the ex- tremely brave step of disclosing she is transgender and sought sup- port from her colleagues in making the public announcement and private transition. Instead of support, when she came out to the Sheriff, he asked, “[w]hat the hell is he [Deputy Lange] talking about[,]” exclaimed he “thought it was a joke,” and said, “I don’t believe in sex changes.” The Sheriff then called a group meeting to discuss “a sensitive and a serious subject,” where he proclaimed, “I don’t believe in all this,” and that what Deputy Lange did “takes big balls.” Nevertheless, Deputy Lange pushed through in seeking the medical services necessary for her gender dysphoria that, but for

2 What Percentage of the US Population is Transgender?, USAFACTS, https://usa-

facts.org/articles/what-percentage-of-the-us-population-is-transgender (up- dated Feb. 12, 2025) [https://perma.cc/67RE-HKBQ]. USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 72 of 108

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her transgender status, she would have been able to receive through the Houston County’s health insurance coverage policy. Today, the majority upholds Houston County’s policy and practice of denying medically necessary healthcare to an employee simply based on their sex. See Bostock, 590 U.S. at 660 (“An individ- ual’s homosexuality or transgender status is not relevant to em- ployment decisions . . . because it is impossible to discriminate against a person for being homosexual or transgender without dis- criminating against that individual based on sex.”). “Transgender” is a term used to describe a person whose gender identity—a per- son’s inner sense of their gender or lack thereof—differs from the sex they were assigned at birth.3 Gender dysphoria, a medical con- dition recognized by every major medical association and leading world health authority, 4 refers to the “psychological distress that re- sults from an incongruence between one’s sex assigned at birth and one’s gender identity.” 5 Left untreated, gender dysphoria can cause

3 Understanding Transgender People, Gender Identity and Gender Expression, AM.

PSYCH. ASS’N, https://www.apa.org/topics/lgbtq/transgender-people-gen- der-identity-gender-expression (last updated July 8, 2024) [https://perma.cc/JPG8-HURU]. 4 Medical Association Statements in Support of Health Care for Transgender People

and Youth, GLAAD, https://glaad.org/medical-association-statements-sup- porting-trans-youth-healthcare-and-against-discriminatory (last updated June 26, 2024) (providing a comprehensive list of domestic and international health organizations’ recognition of gender dysphoria) [https://perma.cc/28JK- GK8R]. 5 Understanding Transgender People, Gender Identity and Gender Expression, supra

note 3; What is Gender Dysphoria, A M. PSYCH. ASS’N, USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 73 of 108

4 ABUDU, J. Dissenting 22-13626

debilitating anxiety and depression, self-harm, and increased risk of suicide. 6 Treatment for gender dysphoria includes social transition- ing, hormone therapy, and surgical procedures to align a person’s sex characteristics with the person’s gender identity. 7 When, as here, an employer intentionally treats a person worse by limiting access to certain health insurance benefits be- cause they are transgender, the employer has discriminated against that person in violation of Title VII. See Bostock, 590 U.S. at 658; Newport News Shipbuilding & Dry Dock Co. v. EEOC, 462 U.S. 669, 682 (1983). Houston County did not challenge Deputy Lange’s medical diagnosis or that such surgery was part of a transgender person’s transition, and it allowed Deputy Lange to follow the “female dress policy.” However, using a binary gender construct, the majority engages in intellectual gymnastics to delay the inevitable—that transgender people are in the workplace, and they need access to medical procedures that are not uniquely performed on them, but for which transgender people are denied. The Supreme Court’s decision reversing our panel opinion in Bostock is directly on point to the issue here. The employee in

https://www.psychiatry.org/patients-families/gender-dysphoria/what-is- gender-dysphoria (last visited Apr. 8, 2025) [https://perma.cc/EN7A-B94K]. 6 AM. PSYCH. ASS’N, supra note 5; Gender dysphoria, MAYO CLINIC, https://www.mayoclinic.org/diseases-conditions/gender-dysphoria/symp- toms-causes/syc-20475255 (last visited Sept. 5, 2025) [https://perma.cc/N385- RVY4]. 7 AM. PSYCH. ASS’N, supra note 5. USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 74 of 108

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Bostock brought a discrimination suit under Title VII alleging his employer fired him because of his sexual orientation. Although the panel acknowledged Title VII prohibits sex-based discrimination against employees, it held Title VII protections did not encompass sexual-orientation discrimination based on binding circuit prece- dent from Blum v. Gulf Oil Corp., 597 F.2d 936, 938 (5th Cir. 1979) (per curiam). Bostock v. Clayton Cnty. Bd. of Comm’rs, 723 F. App’x 964, 964–65 (11th Cir. 2018) (unpublished) (per curiam) (“Bostock Panel”), rev’d, 590 U.S. 644 (2020). In Blum, an employee filed a Title VII suit alleging he was discharged because of his sexual orienta- tion and ethnicity/religion, but the court held, inter alia, “[d]is- charge for homosexuality is not prohibited by Title VII . . . .” 597 F.2d at 938. The Bostock panel also relied on Evans v. Georgia Regional Hospital, 850 F.3d 1248, 1256 (11th Cir. 2017), as confirmation that Blum remained binding circuit precedent. Bostock Panel, 723 F. App’x at 964–65. In Evans, despite post-Blum Supreme Court deci- sions that interpreted Title VII to include discrimination based on the expression of nonconforming gender characteristics 8 and same- sex sexual harassment,9 we held the employee’s Title VII wrongful

8 Price Waterhouse v. Hopkins, 490 U.S. 228, 235, 250–51 (1989) (holding discrim-

ination based on failure to conform to a gender stereotype is sex-based dis- crimination), superseded on other grounds by statute, Civil Rights Act of 1991, Pub. L. 102-166, 105 Stat. 1075, as recognized in Comcast Corp. v. Nat’l Ass’n of Afr. Am.-Owned Media, 589 U.S. 327, 337 (2020). 9 Oncale v. Sundowner Offshore Servs., Inc., 523 U.S. 75, 81–82 (1998) (holding

“sex discrimination consisting of same-sex sexual harassment is actionable un- der Title VII” and “[t]he prohibition of harassment on the basis of sex requires neither asexuality nor androgyny”). USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 75 of 108

6 ABUDU, J. Dissenting 22-13626

termination claim based on her sexual orientation was foreclosed by Blum. 850 F.3d at 1256. The Bostock panel concluded the post-Blum decisions did not clearly apply to discrimination based on sexual orientation and held it could not overrule Blum, “regardless of whether [they thought] it was wrong,” unless intervening controlling precedent was is- sued. Bostock Panel, 723 F. App’x at 965. In repudiating the Bostock panel opinion, Blum, and Evans, the Supreme Court gave us just that and then some—clear precedent and a straightforward test that applies not only to sexual orientation, but also to transgender status. See Bostock, 590 U.S. at 660. The Court relied on the “ex- press terms” of Title VII and rebuked the employer’s assertion that “‘no one in 1964” when Title VII was passed would have antici- pated the results of its holding, explaining “[n]ot long after the law’s passage, gay and transgender employees began filing Title VII com- plaints, so at least some people foresaw this potential application.” Id. at 653, 676 (citing Smith v. Liberty Mut. Ins. Co., 395 F. Supp. 1098, 1099 (N.D. Ga. 1975) (addressing gender non-conforming claim from 1969), aff’d, 569 F.2d 325 (5th Cir. 1978); Holloway v. Arthur Andersen & Co., 566 F.2d 659, 661 (9th Cir. 1977) (addressing transgender discrimination claim from 1974)). In this case, there is no erroneous prior precedent tying our hands. To the contrary, we have a clear rule directly on point with the case before us. Yet, despite Bostock’s unambiguous directive, the majority goes through a strained analysis to avoid the plain truth that Houston County’s policy violates Title VII on its face. USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 76 of 108

22-13626 ABUDU, J., Dissenting 7

Like the panel in Bostock, the majority ignores or, at best, severely dilutes, Title VII’s express terms. Therefore, the district court’s grant of summary judgment should be affirmed, and the case should be remanded for further proceedings to address Deputy Lange’s request for declaratory and injunctive relief, monetary damages, and attorney’s fees. II. The Majority Opinion Serves as Fodder for Those Who Oppose Legal Rights for Transgender People The majority reaches its conclusion without acknowledging the elephant in the room—transgender rights have come to the forefront of debate in recent years, shining a necessary light on ar- eas of society still rife with discrimination. Since the start of 2025, at least 981 state and federal bills are under consideration and 121 have been passed that address the rights and restrictions placed on transgender individuals in areas such as education, healthcare, ac- cess to public facilities, artistic expression, incarceration, and the military. 10 Many of these bills also address transgender persons and employment issues. 11 While no comment can be made regarding the legality of these legislative efforts, Title VII is broad, inclusive, and clearly prohibits sex-based discrimination against transgender persons in the workplace, just as it prohibits such discrimination against cisgender men and women. See Bostock, 590 U.S. at 683 (ex- plaining “[i]n Title VII, Congress adopted broad language making

10 2025 Anti-Trans Bills Tracker, TRANS LEGIS. TRACKER, https://translegisla-

tion.com (last visited Sept. 4, 2025) [https://perma.cc/C4Z5-G9D8]. 11 Id. USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 77 of 108

8 ABUDU, J. Dissenting 22-13626

it illegal for an employer to rely on an employee’s sex when” taking an adverse employment action). The record is clear that the same surgeries, medications, and mental health treatments that may be covered for some employees also fall under those “certain treatments” not covered for others, and the policy draws the line unequivocally based on transgender status and, therefore, sex. 12 Still, the majority concludes that “[n]othing about the policy exclusion turns on whether the County’s employee is a man or woman,” and “the County’s plan does not facially discriminate based on transgender status,”—es- sentially concluding that the Exclusion applies equally to all people. Maj. Op. at 10, 12. Yet, the argument that a law or policy is valid because it “applies equally to those whom it is applicable” has long been rejected as a basis to justify illegal discrimination. See McLaughlin v. Florida, 379 U.S. 184, 188–90 (1964) (rejecting this principle in striking down a ban on the cohabitation of interracial couples); Loving v. Virginia, 388 U.S. 1, 10 (1967) (same in the con- text of interracial marriage). Instead of exercising our limited role in statutory interpreta- tion by “applying the law’s demands as faithfully as we can,” the majority provides more traction for “extratextual considerations” and “overlook[s] plain statutory commands on the strength of

12 For example, Houston County admitted that a mastectomy for cancer treat-

ment, hormone replacement therapy to treat menopause, and mental healthcare generally are all covered under the policy, but the exclusion would bar coverage of each to treat a transgender employee for gender dysphoria. USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 78 of 108

22-13626 ABUDU, J., Dissenting 9

nothing more than suppositions about intentions or guesswork about expectations.” Bostock, 590 U.S. at 673–74, 681, 683. 13 We need not look hard to find extratextual considerations from groups opposed to transgender equality, as the amicus briefs filed in sup- port of Houston County reveal plenty. The guise of legal analysis soon parts to reveal opposition groups’ true perspective: “[a]ll this is nonsense . . . . Slicing off a male’s genitals is not the same proce- dure as correcting a female’s congenital absence of a vagina,” and “a mastectomy ‘for cancer treatment’ is not the same procedure as removing a woman’s healthy breasts ‘for sex change.’” Brief for Christian Employers Alliance Amicus Curiae in Support of Appel- lants at 14–15, Lange v. Houston County, Docket No. 22-12028 (11th

13 To illustrate, at Oral Argument, an inference was made that perhaps Deputy

Lange’s bottom surgery was so specialized that she had to travel to New York to find a surgeon that could perform it, supporting the Appellant’s assertion that the policy did not draw a line based on transgender status, but rather on the type of procedure. However, transgender rights and protections vary throughout the country, and these geographic disparities, particularly in ac- cess to gender affirming care, may well force transgender people like Deputy Lange to travel out-of-state to obtain medically necessary care. See Map: At- tacks on Gender Affirming Care by State, HUM. RTS. CAMPAIGN (Dec. 4, 2024), https://www.hrc.org/resources/attacks-on-gender-affirming-care-by-state- map [https://perma.cc/6W5X-RJ4G]; Jaclyn M. White Hughto et al., Geo- graphic and Individual Differences in Healthcare Access for U.S. Transgender Adults: A Multilevel Analysis, 3 LGBT HEALTH 424, 431 (2016) (“Our findings uniquely demonstrate that, in addition to individual-level demographic and behavioral factors, the social climate of a state as measured through partisan voting prac- tices is a strong indicator of experiencing care refusal among U.S. transgender individuals.”). USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 79 of 108

10 ABUDU, J. Dissenting 22-13626

Cir. 2024). 14 The disdain is palpable. However, one’s personal be- liefs that promote “transgenderism” 15 do not change the language of Title VII or Bostock’s holding and guidance. “Only the written word is the law, and all persons are entitled to its benefit.” Bostock, 590 U.S. at 653. Access to appropriate medical care is especially important in protecting one’s bodily autonomy. Lange was denied coverage, and thus access, to medically necessary treatment by a healthcare coverage exclusion that limits an adult’s control over their own body. The importance of bodily autonomy crosses political and

14 Amicus Christian Employers Alliance does not hide its goal to stop “gender-

transition mandates” that it claims “coerce . . . employers and healthcare pro- viders to either pay or perform gender-transition surgeries, procedures, coun- seling, or other treatments—all of which are in direct violation of their deeply- held religious beliefs.” Christian Employers Alliance Praises Temporary Injunction to Stay Two Biden Administration Gender-Transition Mandates, CHRISTIAN EMPS. ALL. (May 17, 2022), https://christianemployersalliance.org/wp-content/up- loads/2022/12/5.17.22-CEA-v-EEOC-PR-FINAL.pdf [https://perma.cc/XN3B-5L5J]. Of course, our own precedent recognizes re- ligious exemptions in certain contexts, but Title VII makes no allowance for such extratextual considerations given its express terms prohibit discrimina- tion based on an employee’s transgender status. 15 “Transgenderism” is a term opponents of transgender equality use to imply

that being transgender is an ideology (often political) or a concept, rather than a term that describes a person’s identity. Online Anti-LGBTQ Hate Terms De- fined: “Transgenderism”, GLAAD, https://glaad.org/transgenderism-defini- tion-meaning-anti-lgbt-online-hate (last visited Apr. 9, 2025) [https://perma.cc/Z5GY-EAET]. USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 80 of 108

22-13626 ABUDU, J., Dissenting 11

religious lines16 and has been illustrated by, for example, the recent challenges to mandatory COVID-19 vaccines. 17 As Justice Cardozo famously proclaimed, “[e]very human being of adult years and sound mind has a right to determine what shall be done with [their] own body[.]” Schloendorff v. Soc’y of N.Y. Hosp., 105 N.E. 92, 93 (1914), abrogated on other grounds by Bing v. Thunig, 143 N.E.2d 3 (1957); see also Cruzan v. Dir., Mo. Dep’t of Health, 497 U.S. 261, 278– 79 (1990) (recognizing the constitutional right to bodily autonomy which allows competent persons to refuse unwanted medical treat- ment). Our Constitution does not permit courts to pick and choose which people warrant protection under the law based on the per- sonal views of a subset of the population. 18

16 “If you own yourself, then you have the freedom to make [] personal inti-

mate decisions. Otherwise you are not truly free to exercise any of your other rights.” Christina Sandefur, Bodily Autonomy and Individual Rights, THE FEDERALIST SOCIETY (Dec. 21, 2021), https://fedsoc.org/commentary/fedsoc- blog/bodily-autonomy-and-individual-rights-subtitle-showcase-panel-iv-law- science-and-public-policy [https://perma.cc/C7SR-YHE4]. 17 Katie Mettler et al., Anti-vaccine activists march in D.C. — a city that mandates

coronavirus vaccination — to protest mandates, WASH. POST (Jan. 24, 2022), https://www.washingtonpost.com/dc-md-va/2022/01/23/dc-anti-vaccine- rally-mandates-protest [https://perma.cc/Q8QZ-RUSG]. 18 Justice Barrett, in her concurrence in Skrmetti, proclaimed that transgender

individuals should not be considered a part of a suspect class because such sta- tus is not marked by some “obvious, immutable, or distinguishing character- istic[],” like race or sex. United States v. Skrmetti, 145 S. Ct. 1816, 1851 (2025) (Barrett, J., concurring). Specifically, she contended that individuals experi- ence gender dysphoria at varying ages, and the term “‘transgender’ can de- scribe a huge variety of gender identities and expressions.” Id. at 1852 (internal quotation and citation omitted). Interestingly, Justice Barrett’s arguments USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 81 of 108

12 ABUDU, J. Dissenting 22-13626

III. The Majority Opinion Effectively Sanctions Employ- ment Discrimination Against Transgender People Deputy Lange’s life journey has not unfolded in the neat bi- nary way in which the majority opinion treats her experience and the denial of her employment benefits. As society’s concepts around gender, sex, sexual orientation, and bodily autonomy evolve through time, our Court is expected to help dismantle de jure and de facto forms of discrimination based on these charac- teristics. In the area of sex and gender discrimination, social move- ments have focused on lifting cisgender women out of second- and third-class citizenship. However, instead of extending this progress to all sex- and gender-based classifications, our Court instead is im- posing that lower-class citizenship to a new category—transgender people. Despite persistent attempts to portray the advancement of transgender rights as tantamount to the degradation of the rights of cisgender women 19—in the same way propaganda encouraged

raise the question of whether our caselaw has properly addressed questions around “whiteness” as an immutable characteristic. Our nation’s history shows that not everyone considered “white” today was always viewed that way. Moreover, the phenomenon of mixed-raced people “passing” as white is well-documented, thus supporting the view that “whiteness” is a social con- struct. To push Justice Barrett’s point further, perhaps more exploration is necessary to determine what steps should be taken to authenticate one’s pur- ported “white” racial category. See generally Martha R. Mahoney, Segregation, Whiteness, and Transformation, 143 U. PA. L. REV. 1659, 1660 (1995). 19 See, e.g., Brief for The American Civil Rights Project Amicus Curiae in Sup-

port of Appellants at 8–9, Lange v. Houston County, Docket No. 22-12028 (11th USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 82 of 108

22-13626 ABUDU, J., Dissenting 13

men to believe that rights for women meant a diminishing of their own20—the rights of these two groups are not and have never been mutually exclusive.21 Title VII’s protections against “an employer who intentionally treats a person worse because of sex,” Bostock, 590 U.S. 658, apply equally to all genders—even those whose very existence remains a point of contention. 22 Therefore, recognizing

Cir. 2024) (“Across agencies, the [Biden] Administration maintains that, post- Bostock, statutes prohibiting sex discrimination must be read to cover gender- identity, even at the expense of real women and their spaces that such statutes were explicitly intended to protect.” (emphasis added)); Chan Tov McNamarah, Cis- Woman-Protective Arguments, 123 COLUM. L. REV. 845, 864–68 (2023). 20 See, e.g., Fairchild v. Hughes, 258 U.S. 126, 128 (1922) (plaintiffs arguing that

if women were allowed to vote, men “would be deprived of their right to have such elections duly held, the effectiveness of their votes would be diminished, and election expenses would be nearly doubled. Thus irremediable mischief would result.”); Pamphlets Printed and Distributed by Women’s Anti-Suffrage Asso- ciation of the Third Judicial District of the State of New York (1905), LIBR. OF CONG., https://www.loc.gov/item/06004652 (last visited Apr. 17, 2025) [https://perma.cc/ERH5-3JUX]; Pamphlet Distributed by the National Associa- tion Opposed to Woman Suffrage, JEWISH WOMEN’S ARCHIVE, https://jwa.org/media/pamphlet-distributed-by-national-association-op- posed-to-woman-suffrage (last visited Apr. 17, 2025) [https://perma.cc/FDY8-9CJ5]; Some Reasons Why We Oppose Votes for Women ... National Association Opposed to Woman Suffrage. New York City [1894], LIBR. OF CONG., https://www.loc.gov/resource/rbpe.1300130c?st=image (last vis- ited Apr. 22, 2025) [https://perma.cc/67Y6-26UD]. 21 See generally McNamarah, supra note 19.

22 “For members of the [Christian Employers Alliance] specifically, covering

experimental gender-transition procedures offends religious convictions ‘that male and female are immutable realities defined by biological sex and that gen- der reassignment is contrary to’ their Christian values.” Brief for Christian Employers Alliance Amicus Curiae in Support of Appellants at 16–17, Lange, USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 83 of 108

14 ABUDU, J. Dissenting 22-13626

legal protections for Deputy Lange and other transgender individ- uals in the employment context tracks the reality that transgender individuals often come into the fullness of their identity while they are working adults, and if the workplace is going to be a law-abid- ing environment, it must abide by those legal protections for all of its employees. “[T]he position of women in this country at its inception is reflected in the view expressed by Thomas Jefferson that women should be neither seen nor heard in society’s decisionmaking coun- cils.” Frontiero v. Richardson, 411 U.S. 677, 684 n.13 (1973) (citing MARTIN GRUBERG, WOMEN IN AMERICAN POLITICS 4 (1968) and ALEXIS DE TOCQUEVILLE, DEMOCRACY IN AMERICA (Reeves trans. 1948)). Even after women were granted the right to vote, “for a half century thereafter, it remained the prevailing doctrine that government . . . could withhold from women opportunities ac- corded men so long as any ‘basis in reason’ could be conceived for the discrimination.” United States v. Virginia, 518 U.S. 515, 531 (1996) (Ginsburg, J., majority opinion) (citations omitted). However, as the role of women in society and the concept of gender evolved, so did the law, exemplified by Title VII of the landmark Civil Rights Act of 1964 at issue here that, inter alia, pro- hibited employment discrimination based on sex. 42 U.S.C.

Docket No. 22-12028. Further, the American Civil Rights Project, describes gender affirming care as “psychologically-driven surgical treatments for body dysmorphia.” Brief for The American Civil Rights Project Amicus Curiae in Support of Appellants at iv, Lange, Docket No. 22-12028. USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 84 of 108

22-13626 ABUDU, J., Dissenting 15

§§ 2000e–2000e-17. In 1971, the Supreme Court in Phillips v. Martin Marietta Corp. played its part and held Title VII “requires that per- sons of like qualifications be given employment opportunities irre- spective of their sex,” and concluded it may not permit different hiring policies for women and men based on each having pre- school aged children. 400 U.S. 542, 544 (1971). That said, the Phil- lips Court maintained the presumption that conflicting family obli- gations were a women-specific concern, and “if demonstrably more relevant to job performance for a woman than for a man, could arguably be a basis” for a gender-based distinction in the law. Id. Justice Marshall, concerned with this surviving presumption, explained: “I fear that in this case . . . the Court has fallen into the trap of assuming that the Act permits ancient canards about the proper role of women to be a basis for discrimination. Congress, however, sought just the opposite result.” Id. at 545 (Marshall, J. concurring). That same year, over a hundred years after the ratifi- cation of the Fourteenth Amendment, the Court held for the first time that a law that discriminated against women was unconstitu- tional under the Fourteenth Amendment. U.S. CONST. amend. XIV (ratified on July 9, 1868); Reed v. Reed, 404 U.S. 71, 76–77 (1971) (striking a state statute that mandated preference of men over “equally entitled” women). Thereafter, the Court continued to dismantle our nation’s “long and unfortunate history of sex discrimination,” that was tra- ditionally “rationalized by an attitude of ‘romantic paternalism’ which, in practical effect, put women, not on a pedestal, but in a cage.” Frontiero, 411 U.S. at 684. In Frontiero, the Court recognized USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 85 of 108

16 ABUDU, J. Dissenting 22-13626

that although the position of women had improved, “it can hardly be doubted that, in part because of the high visibility of the sex characteristic, women still face pervasive, although at times more subtle, discrimination in our educational institutions, in the job market and, perhaps most conspicuously, in the political arena.” Id. at 686 (footnotes omitted). Untangling this seemingly subtle dis- crimination meant severing our outdated and disproven concept of gender roles and capacity, and so the Court began striking discrim- inatory state and federal laws which had been based on archaic and overbroad generalizations about gender, particularly rejecting the notion that women were “destined solely for the home and the rearing of the family, and only the male for the marketplace and the world of ideas.” Stanton v. Stanton, 421 U.S. 7, 14–15 (1975) (ci- tation omitted). No longer was the presumption that a woman was depend- ent on a husband, less valuable in the workplace, or less likely to work a viable basis for gender-based distinctions in employment law, property rights, and access to entitlements and benefits.23

23 See, e.g., Weinberger v. Wiesenfeld, 420 U.S. 636, 643 (1975) (rejecting “‘archaic

and overbroad’ generalization[s]” that men financially support their families while women do not); Califano v. Goldfarb, 430 U.S. 199, 206–07 (1977) (similar in the context of social security survivor benefits); Califano v. Westcott, 443 U.S. 76, 91–92 (1979) (rejecting the presumption that fathers are the primary bread- winners while mothers are homemakers); Stanton, 421 U.S. at 14 (rejecting the presumptions that its more important for men to seek higher education and women tend to marry earlier than men); Kirchberg v. Feenstra, 450 U.S. 455, 456, 461 (1981) (rejecting the presumption that, as “head and master” of jointly USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 86 of 108

22-13626 ABUDU, J., Dissenting 17

Acknowledging “[w]omen’s activities and responsibilities [were] in- creasing and expanding,” the Court recognized that “[t]he presence of women in business, in the professions, in government and, in- deed, in all walks of life where education is a desirable, if not al- ways a necessary, antecedent is apparent and a proper subject of judicial notice.” Id. at 15. As late as 1996, the Court struck down the Virginia Military Institute’s categorical exclusion of women and reiterated that precedent does not allow for “a law or official policy [that] denies to women, simply because they are women, full citizenship stature—equal opportunity to aspire, achieve, partici- pate in and contribute to society based on their individual talents and capacities.” United States v. Virginia, 518 U.S. 515, 532 (1996) (citations omitted). 24 Unfortunately, the traditional and stereotypical concepts around sex and gender are still so entrenched in our society’s insti- tutions that to advance sex and gender equality means challenging more than just the laws that make explicit, facial sex- and gender- based criteria. For example, the Court began striking down laws that made distinctions based on pregnancy. See, e.g., Cleveland Bd. of Educ. v. LaFleur, 414 U.S. 632, 645–46 (1974) (rejecting the “con- clusive presumption” that being pregnant made one unfit to work

owned property, a husband possessed a unilateral right to dispose of such property without his wife’s consent). 24 See generally PAULA A. MONOPOLI, CONSTITUTIONAL ORPHAN: GENDER EQUALITY AND THE NINETEENTH AMENDMENT (Oxford Univ. Press 2020) (de- tailing history behind the Nineteenth Amendment’s passage and the litigation efforts toward women’s enfranchisement). USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 87 of 108

18 ABUDU, J. Dissenting 22-13626

in a challenge to a policy that required teachers to take unpaid ma- ternity leave after the first trimester of pregnancy); Nashville Gas Co. v. Satty, 434 U.S. 136, 146 (1977) (striking down policy that de- nied accumulated seniority to employees returning from preg- nancy under Title VII). In interpreting the Pregnancy Discrimina- tion Act of 1978 (“PDA”), which extended Title VII protections by prohibiting discrimination based on pregnancy or pregnancy-re- lated medical conditions, the Court held discrimination based on pregnancy was discrimination based on sex and applied the PDA broadly to include an employee’s spouse in the context of employ- ment benefits. Newport News, 462 U.S. at 684–85; see 42 U.S.C. § 2000e(k). This gradual dismantling of archaic gender concepts goes beyond just their effect on women. In Mississippi University for Women v. Hogan, for example, the Court struck down a nursing school’s categorical exclusion of men and concluded the policy “tends to perpetuate the stereotyped view of nursing as an exclu- sively woman’s job.” 458 U.S. 718, 729 (1982). In Oncale v. Sun- downer Offshore Services, Inc., the Court held that Title VII prohibits same-sex sexual harassment even when both parties are heterosex- ual men, concluding the “harassing conduct need not be motivated by sexual desire to support an inference of discrimination on the basis of sex.” 523 U.S. 75, 80 (1998). Recently, and at issue here, courts have been grappling with our evolving concepts around gender within the context of sexual orientation and gender identity. For instance, the belief that a USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 88 of 108

22-13626 ABUDU, J., Dissenting 19

heterosexual couple is the only proper foundation for marital and familial relationships and, thus, the only family construct entitled to legal protections, has shifted. 25 In the landmark case Obergefell v. Hodges, the Supreme Court held same-sex marriage is a constitu- tional right and that “[t]he limitation of marriage to opposite-sex couples may long have seemed natural and just, but its incon- sistency with the central meaning of the fundamental right to marry is now manifest.” 576 U.S. 644, 670–71 (2015). Further, as the concept of the “gender binary” continues to develop, 26 courts also must continue to develop an effective legal framework to ad- dress discrimination in all its forms. 27 Nevertheless, the Supreme Court already has begun to ad- dress discrimination against transgender persons, some of our most vulnerable citizens, 28 by extending anti-discrimination

25 See I. Bennett Capers, Sex(ual Orientation) and Title VII, 91 COLUM. L. REV.

1158, 1163–64 (1991) (discussing heterosexism as “us[ing] the notion of oppo- site genders to promulgate marital and familial relationships”); see generally Mi- chael J. Rosenfeld, Moving a Mountain: The Extraordinary Trajectory of Same-Sex Marriage Approval in the United States, 3 SOCIUS: SOCIO. RSCH. FOR A DYNAMIC WORLD 1 (2017) [https://doi.org/10.1177/2378023117727658]. 26 See Chassitty N. Fiani & Heather J. Han, Navigating Identity: Experiences of

Binary and Non-Binary Transgender and Gender Non-Conforming (TGNC) Adults, 20 INT’L J. TRANSGENDERISM 181, 181–94 (2019) [https://doi.org/10.1080/15532739.2018.1426074]. 27 See Francisco Valdes, Queers, Sissies, Dykes, and Tomboys: Deconstructing the

Conflation of “Sex,” “Gender,” and “Sexual Orientation” in Euro-American Law and Society, 83 CALIF. L. REV. 1, 23–33 (1995). 28 Poverty rates among the transgender community soar above the national

average. Around 29% of transgender people live in poverty, with even higher USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 89 of 108

20 ABUDU, J. Dissenting 22-13626

frameworks to new contexts. Thus, we arrive back at Bostock, where the Court applied the existing, straightforward “but-for cause” test to hold that under Title VII, “[a]n employer who fires an individual merely for being gay or transgender defies the law.” 590 U.S. at 683. Again, the Court recognized that “homosexuality and transgender status are distinct concepts from sex,” but con- cluded that “sex is necessarily a but-for cause when an employer dis- criminates against homosexual or transgender employees.” Id. at 661, 669.

rates for the Black transgender population (39%) and the Hispanic transgender population (48%). M. V. LEE BADGETT ET AL., LGBT POVERTY IN THE UNITED STATES: A STUDY OF DIFFERENCES BETWEEN SEXUAL ORIENTATION AND GENDER IDENTITY GROUPS 2, 14 (2019), https://williamsinsti- tute.law.ucla.edu/wp-content/uploads/National-LGBT-Poverty-Oct- 2019.pdf [https://perma.cc/AL9V-SZRB]. Attempted suicide rates in the transgender community are as high as 41% compared to 1.6% of the general population, and transgender children grades K-12 have reported alarming rates of harassment (78%), physical assault (35%), and sexual violence (12%). JAMIE M. GRANT ET AL., NAT’L CTR. FOR TRANSGENDER EQUAL. & NAT’L GAY & LESBIAN TASK FORCE, INJUSTICE AT EVERY TURN: A REPORT OF THE NATIONAL TRANSGENDER DISCRIMINATION SURVEY 2–3 (2011) (“INJUSTICE AT EVERY TURN”) [https://perma.cc/8WC3-D62N]; see also Nicolas A. Suarez et al., Disparities in Behaviors and Experiences Among Transgender and Cisgender High School Students—18 U.S. States, 2021, 94 ANNALS OF EPIDEMIOLOGY 113, 113–19 (2024) [https://doi.org/10.1016/j.annepidem.2024.05.004]. The unemploy- ment rate in the transgender community is at least double that of the general population, up to four times that for transgender people of color, and one-fifth of transgender people become homeless at some point because of their transgender status. GRANT, INJUSTICE AT EVERY TURN at 4, 51. USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 90 of 108

22-13626 ABUDU, J., Dissenting 21

In Deputy Lange’s case, we are not tasked with untangling hundreds of years of evolving concepts around gender and sex and their effect on transgender individuals in every conceivable context. Rather, like the early work of eliminating explicit sex- and gender- based distinctions in the law, we only are tasked with reading Hou- ston County’s healthcare exclusions to decide whether they, on their face, treat Deputy Lange worse because she is transgender, i.e., that her sex was the “but-for cause” of Houston County’s deci- sion to deny her medical coverage. The healthcare exclusions do just that. Consequently, the majority opinion traps transgender persons in the category of lower-class citizenship, outside of the protections afforded to cisgender individuals. However, just as “[a] prime part of the history of our Constitution . . . is the story of the extension of constitutional rights and protections to people once ignored or excluded,” Virginia, 518 U.S. at 557, so is our history of requiring all to comply with federal laws that guarantee those pro- tections. The international community is also extending legal protec- tions to transgender persons. The United Nations Commission on Human Rights has clarified that provisions of the Universal Decla- ration of Human Rights, which states “all human beings are born free and equal in dignity and rights,” include transgender persons. 29

29 Rep. of the U.N. High Comm’r for Hum. Rts., ¶ 5, U.N. Doc. A/HRC/19/41 (2011) (quoting G.A. Res. 217 (III) A, Universal Declaration of Human Rights art. 1 (Dec. 10, 1948)) (reporting to the Human Rights Council the results of the study on discriminatory laws and practices against individuals based on their sexual orientation and gender identity) (“The UN Report”). USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 91 of 108

22 ABUDU, J. Dissenting 22-13626

The UN Report is not an aspirational assertion but a recognition that specific, treaty-based international human rights laws include transgender rights.30 For example, the Report reiterates that flow- ing from the International Covenant on Economic, Social and Cul- tural Rights31 is the prohibition of “any discrimination in access to health care and the underlying determinants of health, as well as to means and entitlements for their procurement, on the grounds of sexual orientation and gender identity.” 32 Similarly, an interna- tional group of legal experts developed the Yogyakarta Principles on the Application of International Human Rights Law in Relation to Sexual Orientation and Gender Identity, which provide an “ex- pert exposition of international human rights law as it currently

30 Id. ¶¶ 8–19.

31 International Covenant on Economic, Social and Cultural Rights, opened for

signature Dec. 16, 1966, 993 U.N.T.S. 3 (signed but not ratified by the United States). Even though a State is not bound by a treaty until ratification, Arti- cle 18 of the Vienna Convention on the Law of Treaties provides that, upon signing a treaty, a State “is obliged to refrain from acts which would defeat the object and purpose” of the treaty. Vienna Convention on the Law of Treaties, art. 18(a), May 23, 1969, 1155 U.N.T.S. 331. The United States is also not a party to the Vienna Convention on the Law “but has recognized many of its provisions reflect customary international law.” Kristen E. Eichensehr & Oona A. Hathaway, Major Questions About International Agreements, 172 U. PENN. L. REV. 1845, 1876 n.136 (2024); see also Curtis A. Bradley, Unratified Treaties, Domestic Politics, and the U.S. Constitution, 48 HARV. INT’L L. J. 307, 307–08 (2007) (“Article 18 reflects customary international law that is binding on nations that have not joined the Convention, a claim that the United States has not denied.”). 32 The UN Report, supra note 29, at ¶ 54. USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 92 of 108

22-13626 ABUDU, J., Dissenting 23

applies to the grounds of sexual orientation, gender identity, gen- der expression and sex characteristics.” 33 The Yogyakarta Princi- ples suggest that to protect transgender persons from discrimina- tion in healthcare settings, states should ensure “gender affirming healthcare . . . costs are covered or reimbursable under private and public health insurance schemes.” 34 Since it was published in 2006 and supplemented in 2017, the Yogyakarta Principles have had widespread influence on international and state protections of transgender rights.35 * * * Instead of embracing a legal tradition (and mandate) of up- holding the law to ensure all people are treated equally, or that any

33 THE INT’L COMM’N FOR JURISTS & THE INT’L SERV. FOR HUM. RTS., THE

YOGYAKARTA PRINCIPLES PLUS 10: ADDITIONAL PRINCIPLES ON THE APPLICATION OF INTERNATIONAL HUMAN RIGHTS LAW IN RELATION TO SEXUAL ORIENTATION, GENDER IDENTITY, GENDER EXPRESSION AND SEX CHARACTERISTICS TO COMPLEMENT THE YOGYAKARTA PRINCIPLES 20 (2017) [hereinafter “YOGYAKARTA PRINCIPLES PLUS 10”] [https://perma.cc/P7SU- BM4A]; see also THE INT’L COMM’N OF JURISTS & THE INT’L SERV. FOR HUM. RTS, YOGYAKARTA PRINCIPLES ON THE APPLICATION OF INTERNATIONAL HUMAN RIGHTS LAW IN RELATION TO SEXUAL ORIENTATION AND GENDER IDENTITY 6–9 (2007) [https://perma.cc/K44E-SAJW]. 34 YOGYAKARTA PRINCIPLES PLUS 10, supra note 33, at 20 (Principle 17(L)).

35 See Aoife M. O’Connor et al., Transcending the Gender Binary Under Interna-

tional Law: Advancing Health-Related Human Rights for Trans* Populations, 50 J.L. MED. & ETHICS 409, 414 (2022) [https://doi.org/10.1017/jme.2022.84]; David Brown, Making Room for Sexual Orientation and Gender Identity in International Human Rights Law: An Introduction to The Yogyakarta Principles, 31 MICH. J. INT’L L. 821, 868–74 (2010). USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 93 of 108

24 ABUDU, J. Dissenting 22-13626

treatment is not rooted in a discriminatory purpose or practice, the majority opinion temporarily moves the needle back in the ongo- ing struggle for basic human dignity. Accordingly, I respectfully dissent. USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 94 of 108

22-13626 WILSON, J., Dissenting 1

WILSON, Circuit Judge, joined by ABUDU and KIDD, Circuit Judges, Dissenting: But for her transgender status, Sergeant Anna Lange’s med- ically necessary1 surgery would have been covered by her em- ployer’s health insurance plan. Due to facially discriminatory cov- erage exclusions, it was not. Because discrimination against transgender people is outlawed by Title VII, I dissent. I. Title VII of the Civil Rights Act of 1964 prohibits employers from discriminating against “any individual” with respect to his or her “compensation, terms, conditions, or privileges of employ- ment, because of . . . sex.” 42 U.S.C. § 2000e-2(a)(1). Health insur- ance benefits are “‘compensation, terms, conditions, or privileges of employment.’” E.g., Newport News Shipbuilding & Dry Dock Co. v. EEOC, 462 U.S. 669, 682 (1983) (quoting 42 U.S.C. § 2000e-2(a)). Title VII’s “because of” language incorporates the “but-for” causation standard. Bostock v. Clayton Cnty., 590 U.S. 644, 656 (2020). This test for impermissible discrimination is a “sweeping” one—if an employer relies, even in part, on an employee’s sex

1 Lange’s doctors determined that a vaginoplasty is medically necessary for

Lange’s gender dysphoria under Anthem’s clinical guidelines. Major health professional associations—including the American Medical Association, the Endocrine Society, the American Psychiatric Association, the American Psy- chological Association, the American College of Physicians, the American Os- teopathic Association, and the American College of Obstetrics and Gynecol- ogy—endorse insurance coverage for gender confirming surgeries. USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 95 of 108

2 WILSON, J., Dissenting 22-13626

when deciding to take an adverse employment action, “a statutory violation has occurred.” Id. at 656, 659–60. The “but-for test directs us to change one thing at a time and see if the outcome changes. If it does, we have found a but-for cause.” Id. at 656. A few facts2 illustrate how Houston County’s decision to ex- clude gender confirming care from its insurance plan violates Bos- tock’s but-for test. The health plan covers “medically necessary” services, including “office visits and doctor services,” “diagnostic laboratory” services, “prescription drugs,” “surgical supplies,” “in- patient hospital care,” and “inpatient professional services” includ- ing “surgery” and “general anesthesia.” The plan also has sixty- eight medical exclusions and twenty-nine pharmacy exclusions. Of

2 A few additional facts help illuminate the motives behind Houston County’s

decision to exclude gender affirming care. During its annual renewal, Anthem, the health plan administrator, notified the County that “the exclusion for gen- der identity disorders and sex change surgery will be removed from [Anthem’s 2017] plans” as part of its nondiscrimination mandate, required by the Afford- able Care Act, 42 U.S.C. § 18116; see 42 C.F.R. pt. 92. Although “the County generally follows the recommendation of its third-party administrators as to exclusions for the plan,” Houston County opted out of this nondiscrimination mandate. Anthem notified the County that they would “be responsible for any penalties that result if the plan is determined to be noncompliant.” Later, when Lange met with Sheriff Talton and Houston County Director of Personnel Kenneth Carter to discuss that she is transgender and wanted to live openly as a woman, the Sheriff asked Carter, “What the hell is he talking about?” and commented, “I don’t believe in sex changes.” After the meeting, Carter emailed the County’s insurance broker, informing her that they were “good with nothing being covered.” USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 96 of 108

22-13626 WILSON, J., Dissenting 3

the exclusions, two specifically carve out gender transition care3 from coverage: one excludes coverage for “[s]ervices and supplies for a sex change and/or the reversal of a sex change” (Exclusion 57) and the other “[d]rugs for sex change surgery” (Exclusion 26) (to- gether, the Exclusions). Houston County does not dispute that the Exclusions deny coverage to transgender people seeking treatment for gender dysphoria, even when it is medically necessary, and even when the plan would cover the same treatment for a cis- gender person 4: LANGE’S COUNSEL: Would exclusion 57 exclude a mas- tectomy sought for cancer treatment?

HOUSTON COUNTY REPRESENTATIVE: No.

3 Today, when used for transgender people, these treatments tend to be re-

ferred to as gender transition, gender-affirming, gender confirmation, transgender healthcare, or treatment for gender dysphoria. Appellee Br. at 4. Because the Exclusions refer to this care as for a “sex change,” we use that language at times here. 4 The majority highlights that some of Lange’s other treatments for gender

dysphoria were covered. But they were not supposed to be. The diagnosis for gender dysphoria was “not covered” under the plan. Although Lange initially received treatments because they were not coded for gender dysphoria, the plan withdrew coverage once it discovered the treatments were used to “help someone transition.” These questions and answers come from the Director of Personnel for Hou- ston County’s deposition. Similar responses were given by the Group Account Manager at McNeal Agency, the liaison between Houston County and Blue Cross/Blue Shield, and by the Director of Administration for Houston County as the County’s designated representative. USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 97 of 108

4 WILSON, J., Dissenting 22-13626

LANGE’S COUNSEL: But would exclusion 57 prevent coverage of a mastectomy if it was used to treat gen- der dysphoria?

HOUSTON COUNTY REPRESENTATIVE: Yes.

LANGE’S COUNSEL: Exclusion 26 would not exclude hormone replacement therapy to treat menopause?

HOUSTON COUNTY REPRESENTATIVE: No, not as I un- derstand it.

LANGE’S COUNSEL: But would exclusion 26 prevent hormone replacement therapy if used to treat gender dysphoria?

HOUSTON COUNTY REPRESENTATIVE: As I understand it, yes.

LANGE’S COUNSEL: Is mental healthcare generally cov- ered under the plan?

LANGE’S COUNSEL: So it becomes not covered when it’s related to transgender treatment?

HOUSTON COUNTY REPRESENTATIVE: . . . to answer your question, yes. USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 98 of 108

22-13626 WILSON, J., Dissenting 5

Lange sought and was denied a medically necessary vagi- noplasty. If Lange had been assigned female sex at birth,5 her med- ically necessary vaginoplasty would have been covered by the health plan. Because she was not, it was not. The Bostock but-for test reveals that Lange’s sex “play[ed] an unmistakable and impermissible role” in the coverage decision. 590 U.S. at 660. Lange (1) is a woman, (2) was assigned male sex at

5 The majority opinion relies on Frontiero v. Richardson for the proposition that

“sex . . . is an immutable characteristic determined solely by the accident of birth.” 411 U.S. 677, 686 (1973). Even putting aside the contradiction of assert- ing that biological sex is an “immutable” characteristic in a case about some- one trying to change it, the Supreme Court’s Title VII jurisprudence and med- ical evidence caution against accepting this as settled fact or law. First, the Frontiero Court was not referring to individuals who are attempting to change their biological sex to match their gender identity. It made that observation while explaining that laws that classify based on sex are inherently suspect un- der the Equal Protection Clause because sex, like race and national origin, “bears no relation to ability to perform or contribute to society,” and sex-based laws relegate “the entire class of females to inferior legal status without regard to the actual capabilities of its individual members.” Id. at 686–87. Similarly, in Title VII, “[a]n individual’s homosexuality or transgender status is not relevant to employment decisions.” Bostock v. Clayton Cnty., 590 U.S. 644, 660 (2020). But rather than treat sex as “immutable,” Bostock only proceeded on the assumption that “‘sex’ . . . refer[s] only to biological distinctions be- tween male and female.” Id. at 660–61. The “presumption that biological sex is accurately determinable at birth and that it is a static or permanent biological determination” is “medically and sci- entifically flawed.” Adams ex rel. Kasper v. Sch. Bd. of St. Johns Cnty., 57 F.4th 791, 821–22 (11th Cir. 2022) (en banc) (Wilson, J., dissenting). I therefore take issue with the majority’s assertion that sex is an immutable characteristic based on a flawed and unnuanced reading of Frontiero. USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 99 of 108

6 WILSON, J., Dissenting 22-13626

birth, and (3) is seeking a medically necessary vaginoplasty. Hou- ston County excludes this care from its health plan. 6 Changing “one thing,” id. at 656, imagine someone that (1) is a woman, (2) was as- signed female sex at birth, and (3) is seeking a medically necessary vaginoplasty. This care would be covered. Therefore, Houston County’s health plan “penalizes a person identified as male at birth for traits or actions that it tolerates in an employee identified as fe- male at birth.” Bostock, 590 U.S. at 660. Because the individual’s sex is a but-for cause of the denial of coverage, the plan violates Title VII. While Title VII’s “because of” language, operationalized through Bostock’s “but-for” test, is a “sweeping” discrimination standard designed to ensure that Title VII’s protected characteris- tics play no role in employment decisions, the test is still subject to different formulations. Bostock, 590 U.S. at 656. For example, take the majority’s but-for analysis. First, it presents Lange, a “natal man,” who sought a male-to-female sex change. The majority then hypothesizes “a natal woman who wanted a female-to-male sex change.” In this hypothetical the majority changes two things, both

6 Both parties agree that cost was not a factor in the County’s decision to opt

out of the nondiscrimination mandate. Lange’s surgery was estimated to cost $25,600, and she is the only employee under the County’s health plan to seek this treatment. The almost $1.2 million that Houston County has spent on this litigation would have covered approximately forty-six of the procedures Lange requested and equates to almost three times the County’s annual physical and mental health budget. Aliyya Swaby & Lucas Waldron, This Georgia County Spent $1 Million to Avoid Paying for One Employee’s Gender-Affirming Care, ProPublica (Mar. 19, 2023), https://perma.cc/56FU-94C6. USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 100 of 108

22-13626 WILSON, J., Dissenting 7

the person’s sex assigned at birth and the treatment they are seek- ing. This is contrary to Bostock’s mandate that we “change one thing.” Bostock, 590 U.S. at 656. The majority then tries another formulation of Bostock’s “simple test.” It hypothesizes “a natal woman who sought cover- age for the same male-to-female sex change that Lange received.” For starters, someone assigned female sex at birth would not seek a male-to-female sex change unless they had previously transi- tioned. This scenario would entail changing multiple variables at one time, again violating Bostock’s mandate. The majority’s test then, seems to depend on the idea that the Exclusions are made nondiscriminatory by a cisgender person who would have to pay out of pocket for their transgender depend- ent’s surgery. This argument defies logic. The Exclusions discrimi- nate based on sex, regardless of whether the person being discrim- inated against is an employee or the dependent of an employee. The majority’s claim that “[n]othing about the policy exclu- sion turns on whether the County’s employee is a man or woman” ignores that the Exclusions themselves are impermissibly “bound up with sex.” Bostock, 590 U.S. at 661. So “[a]n employer musters no better defense by responding that it is equally happy to [exclude] male and female employees” from this coverage. Id. at 662. Indeed, to apply the Exclusions, the plan administrator would have to know the purpose of the procedure—if for a “sex change” or a “sex change reversal,” it is excluded, but if for some- thing else, it is covered. To determine whether the care is for a “sex USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 101 of 108

8 WILSON, J., Dissenting 22-13626

change,” “sex change reversal,” or something else, the administra- tor must look at a person’s sex—their sex assigned at birth, what it is now, and what they intend it to be in the future. Then, and only then, can the administrator decide whether the care is covered or not covered. So, inquiring into the purpose of the care necessarily entails inquiring into, and denying benefits based on, sex. “There is no way” to determine whether coverage will be provided “without considering [an employee’s] sex” assigned at birth and then exclud- ing coverage based on that finding. Bostock, 590 U.S. at 668. The fact that Bostock’s “but-for” test is subject to manipula- tion is no indication that the Exclusions are facially nondiscrimina- tory. Discrimination has been reframed in neutral terms in the past. 7 For example, in Loving v. Virginia, the Court confronted the

7 See Plessy v. Ferguson, 163 U.S. 537, 548 (1896) (finding that “enforced separa-

tion” of Black and white persons did not violate the Equal Protection clause), overruled by Brown v. Board of Ed., 347 U.S. 483, 495 (1954) (“Separate educa- tional facilities are inherently unequal.”); Pace v. Alabama, 106 U.S. 583, 585 (1883) (upholding a law under the Equal Protection Clause that punished “for- nication” between people of different races more severely than “fornication” between people of the same race because both races received increased pun- ishment for interracial “fornication”), overruled by McLauglin v. Florida, 379 U.S. 184, 188–190 (1964) (“This narrow view of the Equal Protection Clause was soon swept away.”); General Elec. Co. v. Gilbert, 429 U.S. 125, 138–39 (1976) (holding that the exclusion of pregnancy-related disabilities from the insurance plan did not violate Title VII even though the exclusion impacted one gender more than the other), superseded by statute as stated in Newport News Shipbuilding and Dry Dock Co. v. EEOC, 462 U.S. 669, 678 (1983) (Congress “unambiguously expressed its disapproval of both the holding and the reasoning of the Court in the Gilbert decision.”); Korematsu v. United States, 323 U.S. 214, 223–24 (1944) (“To cast this case into outlines of racial prejudice, without reference to the USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 102 of 108

22-13626 WILSON, J., Dissenting 9

argument that anti-miscegenation laws were permissible because they “punish[ed] equally” both the Black and white participants in an interracial marriage. 388 U.S. 1, 8 (1967). But the Court “re- ject[ed] the notion that the mere ‘equal application’ of a statute containing racial classifications is enough to remove the classifica- tions from the Fourteenth Amendment’s proscription of all invidi- ous racial discriminations.” Id. We are not the first to make this point. See United States v. Skrmetti, 145 S. Ct. 1816, 1877 (2025) (So- tomayor, J., dissenting). But it is particularly apt here, where the majority recasts sex discrimination as a neutral policy excluding “sex change operation[s] for anyone regardless of their biological sex.” Just as the illegality of a marriage under the statutes in Loving hinged on a person’s race, so too here do the Exclusions hinge on a person’s sex.

real military dangers which were presented, merely confuses the issue. Kore- matsu was not excluded from the Military Area because of hostility to him or his race. He was excluded because we are at war with the Japanese Em- pire . . . .”) overruled by Trump v. Hawaii, 585 U.S. 667, 710 (2018) (“The forcible relocation of U.S. citizens to concentration camps, solely and explicitly on the basis of race, is objectively unlawful and outside the scope of Presidential au- thority. But it is wholly inapt to liken that morally repugnant order to a facially neutral policy denying certain foreign nationals the privilege of admission.”); but see Trump, 585 U.S. at 754 (Sotomayor, J., dissenting) (“By blindly accepting the Government’s misguided invitation to sanction a discriminatory policy motivated by animosity toward a disfavored group, all in the name of a super- ficial claim of national security, the Court redeploys the same dangerous logic underlying Korematsu and merely replaces one ‘gravely wrong’ decision with another.”). USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 103 of 108

10 WILSON, J., Dissenting 22-13626

Courts have time and again pointed to a purported nondis- criminatory reason rather than grapple with the discriminatory terms of a statute or policy. Ignoring that the Exclusions hinge on sex is antithetical to Title VII’s “momentous” message that “[a]n individual employee’s sex is not relevant to the selection, evalua- tion, or compensation of employees.” Id. at 660 (internal quotation marks omitted). II. The majority opinion relies heavily on United States v. Skrmetti, 145 S. Ct. 1816 (2025). But this reliance is misplaced. Alt- hough the Court conducted an analysis under Bostock, 8 the Court declined to address “whether Bostock’s reasoning reaches beyond the Title VII context.” Id. at 1834–35. And Skrmetti arose under the Equal Protection Clause, where our conception of discrimination is quite different from that under Title VII. 9 The differences begin with the text.

8 The but-for analysis was not necessary to deciding the case and is therefore

dicta. See United States v. Caraballo-Martinez, 866 F.3d 1233, 1244 (11th Cir. 2017). 9 Recently, Justice Gorsuch pointed to the differences between Title VI (whose

language is “materially identical” to Title VII) and the Equal Protection Clause in his concurrence in Students for Fair Admissions, Inc. v. President & Fellows of Harvard College, 600 U.S. 181, 302, 308–09 (2023) (Gorsuch, J., concurring). Jus- tice Gorsuch explained: Consider just some of the obvious differences. The Equal Pro- tection Clause operates on States. It does not purport to regu- late the conduct of private parties. By contrast, Title VI applies to recipients of federal funds—covering not just many state USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 104 of 108

22-13626 WILSON, J., Dissenting 11

The Equal Protection Clause of the Fourteenth Amendment provides: “No State shall . . . deny to any person within its jurisdic- tion the equal protection of the laws.” U.S. Const. amend XIV § 1. It does not contain the phrase “because of” or any similar phrase that adopts a test of but-for causation. Our equal protection jurisprudence has developed to “coex- ist with the practical necessity that most legislation classifies for one purpose or another, with resulting disadvantage to various groups or persons.” Romer v. Evans, 517 U.S. 620, 631 (1996). The Court has never taken a but-for approach to equal protection classifications. The contrast between the stringency of the but-for test’s operation and the flexibility of the Court’s equal protection classifications is nowhere clearer than it is in the Court’s sexual orientation discrim- ination cases.

actors, but many private actors too. In this way, Title VI reaches entities and organizations that the Equal Protection Clause does not. In other respects, however, the relative scope of the two provisions is inverted. The Equal Protection Clause addresses all manner of distinctions between persons and this Court has held that it implies different degrees of judicial scru- tiny for different kinds of classifications. . . . By contrast, Title VI targets only certain classifications—those based on race, color, or national origin. And that law does not direct courts to subject these classifications to one degree of scrutiny or an- other. Instead, as we have seen, its rule is as uncomplicated as it is momentous. Under Title VI, it is always unlawful to dis- criminate among persons even in part because of race, color, or national origin. Id. (internal citations omitted). USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 105 of 108

12 WILSON, J., Dissenting 22-13626

The Court has never treated sexual orientation as a form of sex discrimination, requiring heightened scrutiny, under the Equal Protection Clause. Even in decisions recognizing constitutional protections for the LGBTQ community, such as in Romer v. Evans,10 Lawerence v. Texas, 11 United States v. Windsor, 12 and Obergefell v. Hodges, 13 the Court has consistently avoided the question of whether sexual orientation should be deemed a suspect or quasi- suspect class. Most recently, in Skrmetti, it avoided deciding whether laws classifying based on transgender status are subject to heightened scrutiny as sex discrimination. 145 S. Ct. at 1832–33. Not so under Title VII, which “requires that we focus on fairness to individuals rather than fairness to classes.” L.A. Dep’t of Water & Power v. Manhart, 435 U.S. 702, 709 (1978). Title VII’s

10 517 U.S. 620, 624, 632–34 (1996) (invalidating a Colorado statute under the

Equal Protection Clause that prohibited the enactment of laws that would al- low gay people to “claim any minority status, quota preferences, protected status or claim of discrimination” because it failed rational basis review). 11 539 U.S. 558, 562, 575, 578–79 (2003) (declining to hold a Texas statute that

made “it a crime for two persons of the same sex to engage in certain intimate sexual conduct” invalid under the Equal Protection Clause instead finding that it violated the Due Process Clauses of the Fifth and Fourteenth Amendments). 12 570 U.S. 744, 775 (2013) (invalidating Section 3 of the Defense of Marriage

Act, which provided a federal definition of marriage to mean “only a legal un- ion between one man and one woman,” 1 U.S.C. § 7, because it failed rational basis review). 13 576 U.S. 644, 675 (2015) (holding laws that prohibit same-sex marriages are

unconstitutional under the Due Process and Equal Protection Clauses of the Fourteenth Amendment but not applying heightened scrutiny). USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 106 of 108

22-13626 WILSON, J., Dissenting 13

stricter “but-for” test is “‘simple but momentous’: An individual employee’s sex is ‘not relevant to the selection, evaluation, or com- pensation of employees.’” Bostock, 590 U.S. at 660 (quoting Price Waterhouse v. Hopkins, 490 U.S. 228, 239 (1989)). And “it is impossi- ble to discriminate against a person for being homosexual or transgender without discriminating against that individual based on sex.” Id. at 660–62. The majority opinion’s argument that “‘the law does not prohibit conduct for one sex that it permits for the other,’” is a group level discrimination argument that is no good under Title VII. It is no “defense for an employer to say it discriminates against both men and women because of sex. This statute works to protect individuals of both sexes from discrimination, and does so equally.” Bostock, 590 U.S. at 659. Perhaps most telling of the differences in how we conceive of discrimination under the Equal Protection Clause and Title VII is the evolution of the Court’s treatment of another form of sex discrimination—pregnancy discrimination. In 1974, the Court con- sidered whether an insurance program that excluded from cover- age certain disabilities resulting from pregnancy discriminated on the basis of sex. Geduldig v. Aiello, 417 U.S. 484, 486 (1974). The Court reasoned that there was a “lack of identity” between sex and pregnancy because the plan divided participants into two groups— “pregnant women and nonpregnant persons.” Id. at 496 n.20. Be- cause women could belong to either group, there was no discrimi- nation based on sex as such. Id. Gilbert followed next, and the USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 107 of 108

14 WILSON, J., Dissenting 22-13626

Supreme Court upheld a disability plan that excluded disabilities arising from pregnancy, relying largely on Geduldig’s reasoning. General Elec. Co. v. Gilbert, 429 U.S. 125, 132–34 (1979). Today, this kind of reasoning lives on in the equal protection context. See, e.g., Adams by & through Kasper v. Sch. Bd. of St. Johns Cnty., 57 F.4th 791, 809 (11th Cir. 2022) (en banc). The Court in Skrmetti found that excluding medical treatments for gender dys- phoria does not discriminate on the basis of transgender status be- cause “although only transgender individuals seek treatment for gender dysphoria . . . —just as only biological women can become pregnant—there is a ‘lack of identity’ between transgender status” and the exclusion of gender dysphoria treatment. 145 S. Ct. at 1833. Instead, the law at issue divided people into two groups: those that seek puberty blockers and hormones to treat gender dysphoria, which only includes transgender individuals, and those who might seek puberty blockers or hormones to treat other conditions. Id. The latter group encompasses both transgender and non- transgender individuals, so the Court concluded the law did not “exclude any individuals on the basis of transgender status.” Id. at 1833–34. Here, the majority opinion uses this reasoning to decide that the “County’s plan does not facially discriminate based on transgender status” but rather “draws a line between certain treat- ments, which it covers, and other treatments, which it does not.” But this reasoning is particularly inappropriate in Title VII cases. Congress amended Title VII in response to Gilbert and “un- ambiguously expressed its disapproval” of this reasoning. Newport USCA11 Case: 22-13626 Document: 173-1 Date Filed: 09/09/2025 Page: 108 of 108

22-13626 WILSON, J., Dissenting 15

News, 462 U.S. at 678. The House and Senate Reports expressed that the Gilbert’s dissenters “correctly interpreted the Act.” Id. (quo- tation mark omitted). The dissenters argued that it “was inaccurate to describe the program as dividing potential recipients into two groups, pregnant women and non-pregnant persons, because in- surance programs ‘deal with future risks rather than historic facts.’ Rather, the appropriate classification was ‘between persons who face a risk of pregnancy and those who do not.’” Id. (quoting Gil- bert, 429 U.S. 161–62 (Stevens, J., dissenting)). Applying the correct discrimination standard from the Gil- bert dissenters, transgender individuals are the only ones that face the “risk” of needing a “sex-change” or “sex-change reversal.” By excluding medically necessary care if it is classified as a “sex- change” or “sex-change reversal” the health plan provides less com- plete coverage for people based on their transgender status, and therefore also based on their sex. See Bostock, 590 U.S. at 660–62. This violates Title VII. III. Because the majority manipulates Bostock’s but-for test to obfuscate the discrimination apparent on the face of the plan, I dis- sent.