Federal Government
4th Circuit rules gender identity is a protected characteristic
Ruling a response to N.C., W.Va. legal challenges
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 stateās 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 āapply 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 āapplying 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:

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, āgender 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 āXX chromosomesā and āXY chromosomesā to get around sex discrimination policies:
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 Actās 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 Circuitās 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 Carolinaās 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, āThe courtās 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.
Federal Government
HHS āpeer-reviewedā report calls gender-affirming care for trans youth dangerous
Advocates denounce document as āsham science’
The U.S. Department of Health and Human Services on Nov. 19 released what it called an updated āpeer 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 āvulnerable children.ā
āThe report, released through the Office of the Assistant Secretary of Health, finds that the harms from sex-rejecting procedures ā including puberty blockers, cross-sex hormones, and surgical operations ā 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.
āThe 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, āThey betrayed their oath to first do no harm, and their so-called āgender affirming careā 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 āa 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 HHSās so-called peer reviewed report is similar to an earlier HHS report released in May that had a āpredetermined 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, āTrans peopleās 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 ādiscredited junk science.ā She added the report makes claims that are āgrossly 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.
āBefore 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 āgender dysphoria,āā the statement continues. āThe 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, āOur 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
President Donald Trump on Wednesday signed a bill that reopens the federal government.
Six Democrats ā 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.) ā voted for the funding bill that passed in the U.S. House of Representatives. Two Republicans ā Thomas Massie (R-Ky.) and Greg Steube (R-Fla.) ā opposed it.
The 43-day shutdown is over after eight Democratic senators gave in to Republicansā 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 ā 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.) ā 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 āa victoryā because it gives Democrats āan 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 governmentās reopening also brought a win for Democratsā 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.
Federal Government
41 days and counting: Arizonaās Adelita Grijalva says ‘this has gone way too far’
Representative Adelita Grijalva sits down with the Blade to discuss the Epstein files, transgender rights, and her fight to represent Arizona.
Adelita Grijalva, the recently elected representative from Arizonaās Seventh Congressional District, has already begun making historyāwithout having stepped foot into the Capitol. Grijalva is now officially the longest-delayed member of the House to be sworn inā41 days and counting.
She was elected in a special election on Sept. 23 by a two-to-one margin over her Republican opponent, following the death of her father, RaĆŗl Grijalva, who had represented the district from 2003 until early 2025. The district includes a large portion of Arizonaās southern border with Mexico.
Despite being elected more than 40 days ago, Grijalva has not been given the opportunity to begin her work representing Arizona in the House of Representatives.
Mike Johnson, the Speaker of the House and a representative from Louisiana, has offered several explanations for the delay in swearing in Grijalvaāranging from waiting until all votes were certified in the special election (despite not requiring Republicans who also won special elections to wait) to claiming the House needed to return from recess (despite precedent showing new members are typically sworn in the day after their election, regardless of whether the House is in session). Most recently, Johnson has said Grijalva will not be sworn in until the government reopens.
The Washington Blade sat down with Grijalva to discuss the historic delay in her swearing-in, the importance of protecting transgender rights, book bans, environmental issues, and much more.
While Speaker Johnson has given many explanations for the delay, Grijalva said one stands out above the restāthe Epstein files. She ran on a promise to sign a discharge petition to force a vote for the release of the complete Epstein files, a hypothesized document containing the names of high-profile clients to whom the American financier and convicted child sex offender Jeffrey Epstein trafficked young girls. Her signature on the petition would be the 218th, the minimum number required to force a vote.
āIāve now broken all the records for speaker obstruction. Nobody else has ever had to wait this long just to represent their constituents… I never received one communication directly from his office,ā Grijalva said of Speaker Johnsonās lack of reasoning for the delay. āIt seems to me theyāre doing everything they can to stop the release of the Epstein files, and I just donāt know what else it could be.ā
She added that Johnsonās obstruction isnāt just about herāitās about the people she was elected to serve.
āWe have 812,000 people here in Congressional District 7, and my problem is thereās so much we canāt do,ā she said. āSo when Speaker Johnson has little side comments to say about what I should and shouldnāt be doing, itās likeāwhy donāt you do your job so I can do mine?ā
For Grijalva, the issue isnāt partisanāitās about principle. āIt shouldnāt matter my party. I won my election fairly and legally, and thereās no reason why my voters should be punished because the Speaker doesnāt like what I stand for,ā she said.
She also pointed out the irony that her call for transparency on the Epstein files mirrors one made by Donald Trump himself during his presidential campaign.
āTrump ran on day one, āIām going to release those files,ā and I think he got into office, saw what was in them, and said, āMaybe we wait on that,āā she explained. āThatās what I feel is happening nowātheyāre trying to delay and distract from something thatās going to make a lot of powerful people look bad.ā
Still, Grijalva said not all Republicans support Johnsonās decision to keep her from being sworn in. āA couple Republicans have said, āYeah, she should be sworn in. This is crazy.ā I appreciate thatāit shouldnāt matter my party. I should be sworn in, period. I think some people on their side know this has gone way too far.ā
As the government shutdown drags on, Grijalva said the consequences of congressional inaction are becoming increasingly dire for ordinary Americans.
āWhoās really suffering are the federal workersāpeople on federal grants, SNAP benefitsāwho donāt know when theyāll get their next paycheck or how theyāll feed their families,ā she said. āThese are real-life consequences while they play political games.ā
Her frustration over the Epstein files remains steadfast. Grijalva said accountability and transparency must come before politics.
āI donāt care whoās implicated. I donāt care what party they are. If you committed a crimeāif you raped children and womenāyou deserve legal consequences. Survivors deserve transparency and justice so they can begin healing.ā
Beyond political accountability, Grijalva also emphasized the urgent need to address environmental degradationāa crisis that hits especially close to home.
āTrump doesnāt care about our environment. If thereās a dollar to be made, heās going to do it, and heās not thinking about the long-term consequences for people who actually have to live with the damage,ā she said.
The Trump-Vance administration has rolled back a slew of Biden-era environmental policies, from pulling the U.S. out of the Paris Climate Accords to weakening pollution standards and expanding drilling for fossil fuels. For Grijalva, these choices have real, human consequences.
āMy dad lived in a Superfund site and drank poisoned water for 15 years. Cancer is now part of our family because of that. These policies arenāt abstractāthey hurt real people.ā
Her father, the late RaĆŗl Grijalva, passed away from lung cancer earlier this year. The Environmental Working Group estimates that between 100,000 and 122,000 cancer cases in the U.S. may stem from contaminated waterāsomething Grijalva said her family understand all too well.
She also pointed out how allowing environmental destruction by repealing laws meant to protect natural resources threatens Arizonaās economy and identity.
āArizona is an ecotourism hotspotāthere are thousands of jobs tied to protecting our lands. When you destroy it, you canāt put it back together,ā she said. āThe mining laws are so old that we donāt even get any proceeds for years. Itās like someone digging in your backyard, taking your gold, and then telling you to buy it back later.ā
āWhen people say environmental protection isnāt a priority, I just think of my dad and of our state,ā she added. āYou donāt gamble with peopleās health for a quick profit.ā
Shifting to social issues, Grijalva spoke at length about protecting transgender rights during a time when manyāparticularly on the rightācontinue to villainize the community.
āTrans rights are human rights. Thatās it,ā she said firmly. āWhen I say Iāll speak up for those who donāt feel they have a voice, I mean everybodyāespecially people whoāve been pushed to the margins.ā
She didnāt shy away from calling out members of her own party who, in her view, havenāt done enough. āItās disappointing that some Democrats are willing to stay silent as a whole community is being attacked,ā she said. āMaybe theyāve never known what itās like to be targeted, but once you have, you stand up for those who need more support.ā
āI believe gender-affirming care is life-saving care,ā she continued. āWe have to push back against these anti-LGBTQ laws and fight for the Equality Act because the federal government has a responsibility to protect people, not erase them.ā
āItās not the governmentās business who you love or who you are,ā she added. āYou should have the autonomy to be whoever you want to beāthat is America.ā
The congresswoman also spoke passionately about the growing movement to ban books and target librariesāsomething she called ādeeply personal.ā
āIām not only the wifeāIām the daughter and sister of librarians,ā Grijalva said with a laugh. āSo if Iām not an advocate for our libraries, Iām in a lot of trouble. There should not be banned books. Those stories are a lifeline for students who donāt have support at home.ā
She recalled a conversation that underscored her frustration with the movement. āA woman once showed me a book and said, āDo you think this should be available to children?ā I said, āAre the pictures anatomically inaccurate? Because if theyāre correct, why do you care?ā We shouldnāt be policing truth or reality just because it makes some adults uncomfortable.ā
Public service, for Grijalva, has always been personal. She was the youngest woman ever elected to the Tucson Unified School District Governing Board in 2002 and served in that role for 20 yearsāmaking her one of the longest-serving board members in history.
āIāve been in elected office for 22 years,ā she reflected. āPeople from high school tell me Iām the same personāand thatās what I want. You donāt let the environment change you; you change the environment.ā
āI always have to look my kids in the eye at the end of the day,ā she added. āIf I have to explain a vote too much, then itās wrong. Thatās the standard I hold myself to.ā
Even amid the uncertainty of her delayed swearing-in, Grijalva said she remains focused on the people she was elected to serve.
āThe privilege of being able to speak for 812,000 peopleāitās overwhelming, but itās such an honor,ā she said. āIām excited to get sworn in and finally start doing the work my community sent me to do.ā
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