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4th Circuit rules gender identity is a protected characteristic

Ruling a response to N.C., W.Va. legal challenges

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Lewis F. Powell Jr. Courthouse in Richmond, Va. (Photo courtesy of the U.S. Courts/GSA)

BY ERIN REED | The 4th U.S. Circuit Court of Appeals ruled Monday that transgender people are a protected class and that Medicaid bans on trans care are unconstitutional.

Furthermore, the court ruled that discriminating based on a diagnosis of gender dysphoria is discrimination based on gender identity and sex. The ruling is in response to lower court challenges against state laws and policies in North Carolina and West Virginia that prevent trans people on state plans or Medicaid from obtaining coverage for gender-affirming care; those lower courts found such exclusions unconstitutional.

In issuing the final ruling, the 4th Circuit declared that trans exclusions were “obviously discriminatory” and were “in violation of the equal protection clause” of the Constitution, upholding lower court rulings that barred the discriminatory exclusions.

The 4th Circuit ruling focused on two cases in states within its jurisdiction: North Carolina and West Virginia. In North Carolina, trans state employees who rely on the State Health Plan were unable to use it to obtain gender-affirming care for gender dysphoria diagnoses.

In West Virginia, a similar exclusion applied to those on the state’s Medicaid plan for surgeries related to a diagnosis of gender dysphoria. Both exclusions were overturned by lower courts, and both states appealed to the 4th Circuit.

Attorneys for the states had argued that the policies were not discriminatory because the exclusions for gender affirming care ā€œapply to everyone, not just transgender people.ā€ The majority of the court, however, struck down such a claim, pointing to several other cases where such arguments break down, such as same-sex marriage bans ā€œapplying to straight, gay, lesbian, and bisexual people equally,ā€ even though straight people would be entirely unaffected by such bans.

Other cases cited included literacy tests, a tax on wearing kippot for Jewish people, and interracial marriage in Loving v. Virginia.

See this portion of the court analysis here:

4th Circuit rules against legal argument that trans treatment bans do not discriminate against trans people because ‘they apply to everyone.’

Of particular note in the majority opinion was a section on Geduldig v. Aiello that seemed laser-targeted toward an eventual U.S. Supreme Court decision on discriminatory policies targeting trans people. Geduldig v. Aiello, a 1974 ruling, determined that pregnancy discrimination is not inherently sex discrimination because it does not “classify on sex,” but rather, on pregnancy status.

Using similar arguments, the states claimed that gender affirming care exclusions did not classify or discriminate based on trans status or sex, but rather, on a diagnosis of gender dysphoria and treatments to alleviate that dysphoria.

The majority was unconvinced, ruling, ā€œgender dysphoria is so intimately related to transgender status as to be virtually indistinguishable from it. The excluded treatments aim at addressing incongruity between sex assigned at birth and gender identity, the very heart of transgender status.ā€ In doing so, the majority cited several cases, many from after Geduldig was decided.

Notably, Geduldig was cited in both the 6th and 11th Circuit decisions upholding gender affirming care bans in a handful of states.

The court also pointed to the potentially ridiculous conclusions that strict readings of what counts as proxy discrimination could lead to, such as if legislators attempted to use ā€œXX chromosomesā€ and ā€œXY chromosomesā€ to get around sex discrimination policies:

The 4th Circuit majority rebuts the state’s proxy discrimination argument.

Importantly, the court also rebutted recent arguments that Bostock applies only to “limited Title VII claims involving employers who fired” LGBTQ employees, and not to Title IX, which the Affordable Care Act’s anti-discrimination mandate references. The majority stated that this is not the case, and that there is “nothing in Bostock to suggest the holding was that narrow.”

Ultimately, the court ruled that the exclusions on trans care violate the Equal Protection Clause of the Constitution. The court also ruled that the West Virginia Medicaid Program violates the Medicaid Act and the anti-discrimination provisions of the Affordable Care Act.

Additionally, the court upheld the dismissal of anti-trans expert testimony for lacking relevant expertise. West Virginia and North Carolina must end trans care exclusions in line with earlier district court decisions.

The decision will likely have nationwide impacts on court cases in other districts. The case had become a major battleground for trans rights, with dozens of states filing amicus briefs in favor or against the protection of the equal process rights of trans people.Ā Twenty-one Republican statesĀ filed an amicus brief in favor of denying trans people anti-discrimination protections in healthcare, and 17 Democratic statesĀ joined an amicus brief in support of the healthcare rights of trans individuals.

Many Republican states are defending anti-trans laws that discriminate against trans people by banning or limiting gender-affirming care. These laws could come under threat if the legal rationale used in this decision is adopted by other circuits. In the 4th Circuit’s jurisdiction, West Virginia and North CarolinaĀ already have gender-affirming care bans for trans youth in place, andĀ South Carolina may consider a similar bill this week.

The decision could potentially be used as precedent to challenge all of those laws in the near future and to deter South Carolina’s bill from passing into law.

The decision is the latest in a web of legal battles concerning trans people. Earlier this month, the 4th Circuit also reversed a sports ban in West Virginia, ruling that Title IX protects trans student athletes. However, theĀ Supreme Court recently narrowedĀ a victory for trans healthcare from the 9th U.S. Circuit Court of Appeals and allowed Idaho to continue enforcing its ban on gender-affirming care for everyone except the two plaintiffs in the case.

Importantly, that decision was not about the constitutionality of gender-affirming care, but the limits of temporary injunctions in the early stages of a constitutional challenge to discriminatory state laws. It is likely that the Supreme Court will ultimately hear cases on this topic in the near future.

Celebrating the victory, Lambda Legal Counsel and Health Care Strategist Omar Gonzalez-Pagan said in a posted statement, ā€œThe court’s decision sends a clear message that gender-affirming care is critical medical care for transgender people and that denying it is harmful and unlawful … We hope this decision makes it clear to policy makers across the country that health care decisions belong to patients, their families, and their doctors, not to politicians.ā€ 

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Erin Reed is a transgender woman (she/her pronouns) and researcher who tracks anti-LGBTQ+ legislation around the world and helps people become better advocates for their queer family, friends, colleagues, and community. Reed also is a social media consultant and public speaker.

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The preceding article was first published at Erin In The Morning and is republished with permission.

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Federal Government

Holiday week brings setbacks for Trump-Vance trans agenda

Federal courts begin to deliver end-of-year responses to lawsuits involving federal transgender healthcare policy.

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While many Americans took the week of Christmas to rest and relax, LGBTQ politics in the U.S. continued to shift. This week’s short recap of federal updates highlights two major blows to the Trump-Vance administration’s efforts to restrict gender-affirming care for minors.

19 states sue RFK Jr. to end gender-affirming care ban

New York Attorney General Letitia James announced on Tuesday that the NYAG’s office, along with 18 other states (and the District of Columbia), filed a lawsuit to stop U.S. Health and Human Services (HHS) Secretary Robert F. Kennedy Jr. from restricting gender-affirming care for minors.

In the press release, Attorney General James stressed that the push by the Trump-Vance administration’s crusade against the transgender community — specifically transgender youth — is a ā€œclear overreach by the federal governmentā€ and relies on conservative and medically unvalidated practices to ā€œpunish providers who adhere to well-established, evidence-based careā€ that support gender-affirming care.

ā€œAt the core of this so-called declaration are real people: young people who need care, parents trying to support their children, and doctors who are simply following the best medical evidence available,ā€ said Attorney General James. ā€œSecretary Kennedy cannot unilaterally change medical standards by posting a document online, and no one should lose access to medically necessary health care because their federal government tried to interfere in decisions that belong in doctors’ offices. My office will always stand up for New Yorkers’ health, dignity, and right to make medical decisions free from intimidation.ā€

The lawsuit is a direct response to HHS’ Dec. 18 announcement that it will pursue regulatory changes that would make gender-affirming health care for transgender children more difficult, if not impossible, to access. It would also restrict federal funding for any hospital that does not comply with the directive. KFF, an independent source for health policy research, polling, and journalism, found that in 2023 federal funding covered nearly 45% of total spending on hospital care in the U.S.

The HHS directive stems directly from President Donald Trump’s Jan. 28 Executive Order, Protecting Children From Chemical and Surgical Mutilation, which formally establishes U.S. opposition to gender-affirming care and pledges to end federal funding for such treatments.

The American Medical Association, the nation’s largest and most influential physician organization, has repeatedly opposed measures like the one pushed by President Trump’s administration that restrict access to trans health care.

ā€œThe AMA supports public and private health insurance coverage for treatment of gender dysphoria and opposes the denial of health insurance based on sexual orientation or gender identity,ā€ a statement on the AMA’s website reads. ā€œImproving access to gender-affirming care is an important means of improving health outcomes for the transgender population.ā€

The lawsuit also names Oregon, Washington, California, Colorado, Connecticut, Delaware, the District of Columbia, Illinois, Maine, Maryland, Massachusetts, Michigan, Minnesota, New Mexico, Pennsylvania, Rhode Island, Vermont, and Wisconsin as having joined New York in the push against restricting gender-affirming care.

At the HHS news conference last Thursday, Jim O’Neill, deputy secretary of the department, asserted, ā€œMen are men. Men can never become women. Women are women. Women can never become men.ā€

DOJ stopped from gaining health care records of trans youth

U.S. District Judge Cathy Bissoon blocked an attempt by the Department of Justice (DOJ) to gain ā€œpersonally identifiable information about those minor transgender patientsā€ from the University of Pittsburgh Medical Center (UPMC), saying the DOJ’s efforts ā€œfly in the face of the Supreme Court.ā€

Journalist Chris Geidner originally reported the news on Dec. 25, highlighting that the Western District of Pennsylvania judge’s decision is a major blow to the Trump-Vance administration’s agenda to curtail transgender rights.

ā€œ[T]his Court joins the others in finding that the government’s demand for deeply private and personal patient information carries more than a whiff of ill intent,ā€ Bissoon wrote in her ruling. ā€œThis is apparent from its rhetoric.ā€

Bissoon cited the DOJ’s ā€œincendiary characterizationā€ of trans youth care on the DOJ website as proof, which calls the practice politically motivated rather than medically sound and seeks to ā€œā€¦mutilate children in the service of a warped ideology.ā€ This is despite the fact that a majority of gender-affirming care has nothing to do with surgery.

In United States v. Skrmetti, the Supreme Court ruled along party lines that states — namely Tennessee — have the right to pass legislation that can prohibit certain medical treatments for transgender minors, saying the law is not subject to heightened scrutiny under the Equal Protection Clause of the Fourteenth Amendment because it does not involve suspect categories like race, national origin, alienage, and religion, which would require the government to show the law serves a compelling interest and is narrowly tailored, sending decision-making power back to the states.

ā€œThe government cannot pick and choose the aspects of Skrmetti to honor, and which to ignore,ā€ Judge Bissoon added.

The government argued unsuccessfully that the parents of the children whose records would have been made available to the DOJ ā€œlacked standingā€ because the subpoena was directed at UPMC and that they did not respond in a timely manner. Bissoon rejected the timeliness argument in particular as ā€œdisingenuous.ā€

Bissoon, who was nominated to the bench by then-President Obama, is at least the fourth judge to reject the DOJ’s attempted intrusion into the health care of trans youth according to Geidner.

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HHS ā€˜peer-reviewed’ report calls gender-affirming care for trans youth dangerous

Advocates denounce document as ā€˜sham science’

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HHS Secretary Robert F. Kennedy Jr. (Washington Blade photo by Michael Key)

The U.S. Department of Health and Human Services on Nov. 19 released what it called an updated ā€œpeer reviewedā€ version of an earlier report claiming scientific evidence shows that gender-affirming care or treatment for juveniles that attempts to change their gender is harmful and presents a danger to ā€œvulnerable children.ā€

ā€œThe report, released through the Office of the Assistant Secretary of Health, finds that the harms from sex-rejecting procedures — including puberty blockers, cross-sex hormones, and surgical operations — are significant, long term, and too often ignored or inadequately tracked,ā€ according to a statement released by HHS announcing the release of the report.

ā€œThe American Medical Association and the American Academy of Pediatrics peddled the lie that chemical and surgical sex-rejecting procedures could be good for children,ā€ said HHS Secretary Robert F. Kennedy Jr. in  the HHS statement, ā€œThey betrayed their oath to first do no harm, and their so-called ā€˜gender affirming care’ has inflicted lasting physical and psychological damage on vulnerable young people,ā€ Kennedy says in the statement.

The national LGBTQ advocacy organizations Human Rights Campaign and GLAAD issued statements on the same day the HHS report was released, denouncing it as a sham based on fake science and politics.

HRC called the report ā€œa politically motivated document filled with outright lies and misinformation.ā€  

In its own statement released on the same day the HHS report was released, HRC said HHS’s so-called peer reviewed report is similar to an earlier HHS report released in May that had a ā€œpredetermined outcome dictated by grossly uninformed political actors that have deliberately mischaracterized  health care for transgender youth despite the uniform, science backed conclusion of the American medical and mental health experts to the contrary.ā€

The HRC statement adds, ā€œTrans people’s health care is delivered in age-appropriate, evidence-based ways, and decisions to provide care are made in consultation with doctors and parents, just like health care for all other people.ā€

In a separate statement, GLAAD CEO Sarah Kate Ellis called the HHS report a form of ā€œdiscredited junk science.ā€ She added the report makes claims that are ā€œgrossly misleading and in direct contrast to the recommendations of every leading health authority in the world … This report amounts to nothing more than forcing the same discredited idea of conversion therapy that ripped families apart and harmed gay, lesbian, and bisexual young people for decades.ā€

In its statement announcing the release of its report, HHS insists its own experts rather than those cited by its critics are the ones invoking true science.

ā€œBefore submitting its report for peer review, HHS commissioned the most comprehensive study to date of the scientific evidence and clinical practices surrounding the treatment of children and adolescents for ā€˜gender dysphoria,ā€™ā€ the statement continues. ā€œThe authors were drawn from disciplines and professional backgrounds spanning medicine, bioethics, psychology, and philosophy.ā€

In a concluding comment in the HHS statement, Assistant Secretary for Health Brian Christine says, ā€œOur report is an urgent wake-up call to doctors and parents about the clear dangers of trying to turn girls into boys and vice versa.ā€

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Federal government reopens

Shutdown lasted 43 days.

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(Washington Blade photo by Michael Key)

President Donald Trump on Wednesday signed a bill that reopens the federal government.

Six Democrats — U.S. Reps. Jared Golden (D-Maine), Marie Gluesenkamp Perez (D-Wash.), Adam Gray (D-Calif.), Don Davis (D-N.C.), Henry Cuellar (D-Texas), and Tom Suozzi (D-N.Y.) — voted for the funding bill that passed in the U.S. House of Representatives. Two Republicans — Thomas Massie (R-Ky.) and Greg Steube (R-Fla.) — opposed it.

The 43-day shutdown is over after eight Democratic senators gave in to Republicans’ push to roll back parts of the Affordable Care Act. According to CNBC, the average ACA recipient could see premiums more than double in 2026, and about one in 10 enrollees could lose a premium tax credit altogether.

These eight senators — U.S. Sens. Catherine Cortez Masto (D-Nev.), Dick Durbin (D-Ill.), John Fetterman (D-Pa.), Maggie Hassan (D-N.H.), Tim Kaine (D-Va.), Angus King (I-Maine), Jacky Rosen (D-Nev.), and Jeanne Shaheen (D-N.H.) — sided with Republicans to pass legislation reopening the government for a set number of days. They emphasized that their primary goal was to reopen the government, with discussions about ACA tax credits to continue afterward.

None of the senators who supported the deal are up for reelection.

King said on Sunday night that the Senate deal represents ā€œa victoryā€ because it gives Democrats ā€œan opportunityā€ to extend ACA tax credits, now that Senate Republican leaders have agreed to hold a vote on the issue in December. (The House has not made any similar commitment.)

The government’s reopening also brought a win for Democrats’ other priorities: Arizona Congresswoman Adelita Grijalva was sworn in after a record-breaking delay in swearing in, eventually becoming the 218th signer of a discharge petition to release the Epstein files.

This story is being updated as more information becomes available.

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