Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-ca5-23-10078/USCOURTS-ca5-23-10078-0/pdf.json

Parties Involved:
Xavier Becerra
Appellant
James Hurly
Appellee
Susan Neese
Appellee
United States of America
Appellant

Document Text:

5 

United States Court of Appeals

for the Fifth Circuit ____________

No. 23-10078

____________

Susan Neese; James Hurly, 

Plaintiffs—Appellees, 

versus

Xavier Becerra, in his official capacity as Secretary of Health and Human 

Services; United States of America, 

Defendants—Appellants. 

______________________________

Appeal from the United States District Court 

for the Northern District of Texas

USDC No. 2:21-CV-163 

______________________________

Before Jones, Haynes, and Douglas, Circuit Judges.

Per Curiam: 

Dr. Susan Neese and Dr. James Hurly (“Plaintiffs”) brought a preenforcement challenge to the Notification of Interpretation and Enforcement 

of Section 1557 of the Affordable Care Act and Title IX of the Education 

Amendments of 1972 (“Notification”), which was issued by the Department 

of Health and Human Services (“HHS”) in May 2021. The district court 

granted summary judgment for Plaintiffs. Because Plaintiffs lack Article III 

standing, we VACATE the district court’s judgment and REMAND with 

instructions to dismiss Plaintiffs’ claims for lack of jurisdiction. 

United States Court of Appeals

Fifth Circuit

FILED

December 16, 2024

Lyle W. Cayce

Clerk

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No. 23-10078

2

The Notification at issue states that “[c]onsistent with the Supreme 

Court’s decision in Bostock[1

] and Title IX, beginning today, OCR will 

interpret and enforce Section 1557’s prohibition on discrimination on the 

basis of sex[2] to include: (1) [d]iscrimination on the basis of sexual 

orientation; and (2) discrimination on the basis of gender identity.”

Notification of Interpretation and Enforcement of Section 1557 of the 

Affordable Care Act and Title IX of the Education Amendments of 1972, 86 

Fed. Reg. 27984, 27985 (May 25, 2021) (to be codified at 45 C.F.R. pts. 86, 

92). Plaintiffs filed this case in August 2021 to challenge the Notification. 

Both Plaintiffs are doctors in Amarillo, Texas. Dr. Neese practices 

general internal medicine for patients from age 16 to 105 years old. Dr. Hurly 

is a pathologist who diagnoses patients based on laboratory analyses. They 

both claim to be “unwilling to provide gender-affirming care, in at least some 

situations, to patients who assert a gender identity that departs from their 

biological sex.”3 For Dr. Neese, these situations include: (1) her categorical 

unwillingness to assist minors with transitioning or prescribe them puberty 

blockers or hormone therapy (which she explained is not within her medical 

specialty); and (2) her insistence that transgender patients or patients with 

gender dysphoria obtain preventive care consistent with their biological sex, 

such as a biological female who identifies as a man (but whose body remains 

female) undergoing a pelvic examination to check for cervical or ovarian 

cancer. For Dr. Hurly, these situations include informing a biological male 

who identifies as a woman of her prostate cancer diagnosis and need for 

_____________________

1 Bostock v. Clayton Cnty., 140 S. Ct. 1731 (2020). 

2 See 42 U.S.C. § 18116(a); 20 U.S.C. § 1681(a).

3 The parties agree that Plaintiffs only assert an injury caused by the portion of the 

Notification that prohibits discrimination based on gender orientation.

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No. 23-10078

3

treatment. Put another way, the doctors want to be sure that the physical

bodies of their patients are cared for properly.

Neither Plaintiff believes that their medical practices constitute

gender-identity discrimination. However, they are fearful that HHS will 

view their practices as violating the Notification. Plaintiffs fear that HHS will 

bring an enforcement proceeding against them and terminate their federal 

funding if they do not “provide everything a transgender patient might 

demand” (even if it is not doable in their body) or “unconditionally play 

along with a patient’s asserted gender identity.” The Government disagrees 

with the assertion that it would prosecute a doctor who, under the 

circumstances presented in this case, treated a biological male or female 

according to the medical needs of the physical body.

We always have jurisdiction to determine jurisdiction. United States 

v. Ruiz, 536 U.S. 622, 628 (2002). Questions of standing are reviewed de 

novo. N.A.A.C.P. v. City of Kyle, 626 F.3d 233, 236 (5th Cir. 2010). In order 

to have standing, a plaintiff must have suffered an injury that is “concrete 

and particularized” and “actual or imminent, not conjectural or 

hypothetical.” Lujan v. Defs. of Wildlife, 504 U.S. 555, 560 (1992) (quotation 

omitted). The right to pre-enforcement review is qualified and permitted 

only “under circumstances that render the threatened enforcement 

sufficiently imminent.” Susan B. Anthony List v. Driehaus, 573 U.S. 149, 159

(2014); see Whole Woman’s Health v. Jackson, 595 U.S. 30, 49 (2021).

Plaintiffs have not met their burden to establish standing in this case 

because they have not shown how their conduct constitutes gender-identity

discrimination under any plausible reading of the Notification. Plaintiffs 

themselves do not view their conduct as gender-identity discrimination, nor 

do they offer any evidence that HHS will view it as such. They have valid, 

non-discriminatory reasons for their medical practices, including that acting 

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4

otherwise would be malpractice or would require them to provide services 

outside of their specialty areas. Lastly, their current practices have not been 

chilled or otherwise affected, and there is no evidence that an enforcement 

proceeding is imminent. Cf. Braidwood Mgmt. Inc. v. EEOC, 70 F.4th 914, 

929 & n.27 (5th Cir. 2023) (holding plaintiffs had standing to bring preenforcement challenge where the EEOC previously brought an enforcement 

action under similar circumstances). 

Plaintiffs have thus failed to show that they are actually violating the 

Notification, much less that they face a credible threat of enforcement. They

therefore do not have standing.4 Accordingly, we VACATE the district 

court’s judgment and REMAND with instructions to dismiss Plaintiffs’ 

claims for lack of jurisdiction.

_____________________

4 Among other things, the Government challenged the district court’s conclusion 

that the Notification was a final agency action and that Bostock, 140 S. Ct. at 1754, where 

the Supreme Court held that Title VII’s ban on discrimination “because of . . . sex” 

prohibits an employer from firing an employee because that employee is homosexual or 

transgender, does not apply to Title IX or § 1557 of the Affordable Care Act. Because we 

conclude Plaintiffs lack standing, we do not reach the other issues raised in this appeal. 

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5

Edith Hollan Jones, concurring:

Based on representations by counsel for the government during oral 

argument and in brief, I concur in dismissing plaintiffs’ case for lack of Art. 

III standing. I agree with the majority’s conclusions that the plaintiffs “do 

not view their conduct as gender-identity discrimination” because each of 

them treats patients who “identify” as members of the opposite sex. 

Further, as we hold, “[t]hey have valid, non-discriminatory reasons for their

medical practices.” I would add that the government readily affirms the 

plaintiffs are not facing any “credible threat” of prosecution for treating 

biological men or women according to their physical characteristics. See 

Whole Woman’s Health v. Jackson, 142 S.Ct. 522, 536 (2021). Nor do they 

face any credible threat of prosecution for failing to treat patients inconsistent 

with their medical training and practice specialties.

Specifically, HHS judicially admits and confirmed at oral argument 

that “[P]laintiffs do not explain how a medical provider’s care based on a 

transgender patient’s physiological sex characteristics could be considered 

gender-identity discrimination, and HHS has never taken the position that 

such conduct constitutes gender-identity discrimination.” HHS further 

acknowledges that the proposed rule interpreting section 1557 [the rule was 

stayed before it took effect] would not “’prohibit a covered entity from 

treating an individual for conditions that may be specific to their sex 

characteristics,’ such as treating a transgender man with a pregnancy test.” 

[citing 87 Fed. Reg. at 47,866]. HHS also reaffirmed at oral argument that 

“nothing in Section 1557 has ever been taken to mean that a physician must 

provide services outside their [sic] area of specialty.” In sum, nothing in the 

briefing or argument by HHS implies that the plaintiffs faced a credible threat 

of investigation or losing federal funds based on their described medical 

practices.

Case: 23-10078 Document: 90-1 Page: 5 Date Filed: 12/16/2024