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Navigating employer-sponsored health insurance, care

One in four trans patients denied coverage for gender-affirming care

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Even though 86% of transgender Americans have health insurance, one in four reported being denied coverage for gender-affirming care in the 2015 and 2022 U.S. Transgender surveys. These denials can occur when an insurance plan contains a categorical exclusion of gender-affirming care. It is important to note that transgender employees who receive insurance coverage through their employers are entitled to legal protections. 

Employers are responsible for ensuring that the insurance plans they provide do not violate any laws, including anti-discrimination laws. In 1983, the Supreme Court ruled that under Title VII of the Civil Rights Act of 1964, employers are legally required to provide employees with equal pay and benefits, including health insurance. This protection now extends to transgender employees after the Supreme Court’s ruling in Bostock v. Clayton County (2020), which clarified that sex discrimination under Title VII includes gender identity discrimination.

Since Bostock, several transgender employees have successfully sued their employers for discrimination because they were denied coverage of gender-affirming care by their employers’ insurance. While employers can be held liable under Title VII, it remains unclear whether insurance companies will be held liable under Section 1557, the antidiscrimination provision of the Affordable Care Act (ACA), in the future.

Most—if not all—courts have ruled that employers can be held liable for choosing insurance plans with categorical exclusions of gender-affirming care. A categorical exclusion is when an insurance plan has a blanket ban of coverage for certain services. Although discrimination cases generally require proof of intent to discriminate, it is not required of transgender employees because categorical exclusions of gender-affirming care are facially discriminatory (i.e. the policy is explicitly and obviously discriminatory in nature).

In Kadel v. Folwell (2024), the Fourth Circuit court considered the Fourteenth Amendment, Title IX, and ACA claims in a consolidated case considering two state health plans: the State of North Carolina’s insurance plans for teachers and West Virginia’s Medicaid program. The Fourth Circuit court held that it is impossible to ban coverage of gender-affirming care without discriminating against transgender people because (1) gender dysphoria is a legitimate medical diagnosis which requires medically necessary treatment; and (2) the services provided under gender-affirming care are also provided to cisgender patients for other medical diagnoses. In short, there is sufficient evidence of discriminatory intent because categorical exclusions of gender-affirming care are facially discriminatory. Under Kadel, the Fourth Circuit also ruled that a policy does not have to explicitly exclude transgender patients. “Rewording the policies to use a proxy,” like sex changes or sex modification, is still facially discriminatory.

Along a similar vein, in Lange v. Houston County (2024), the Eleventh Circuit court found that the Sheriff’s Office’s categorical exclusion of gender-affirming care was a violation of Title VII. Agreeing with the reasoning in Kadel, the court cited a 1991 Supreme Court Case which ruled that proof of intent to discriminate is not needed for facially discriminatory policies. The court also held Anthem Blue Cross liable because third-party administrators in the Eleventh Circuit (i.e., Alabama, Florida, and Georgia) can be held liable as an employer if they make employment decisions as the authorized agent of an employer. However, this decision is unique to the said jurisdictions, and the liability of third-party administrators/insurance providers remains generally unclear. Moreover, the decision is not final because the court granted an en banc appeal, and a panel of all twelve judges re-heard the case in February 2025. The decision after re-hearing remains to be seen. 

Recently, Executive Order 14168 and the EEOC’s motion to dismiss its lawsuit against Harmony Hospitality on behalf of a transgender worker prompted concerns over transgender employees’ ability to bring federal discrimination claims. While such concerns are understandable, there has yet been any mandate prohibiting the EEOC from issuing right to sue to transgender individuals. In other words, even if the EEOC may not investigate and file lawsuits on behalf of transgender individuals, it does not bar private parties from doing so. Ultimately, the executive branch alone does not have the power to make changes to the Constitution or any federal statutes. It is up to the legislatures to amend laws and the Constitution, and courts to interpret and rule on constitutionality. 

Protections Against Discrimination by Insurers Under Section 1557 Remain Unclear

While employers can be held liable for categorical exclusions of gender-affirming care, employees may be less likely to find relief for legal claims against insurers regarding discrimination on the basis of gender identity. Since Bostock, courts have found insurers liable for denying coverage of gender affirming care under Section 1557 of the ACA, extending sex discrimination to include gender identity. Recent litigation surrounding Section 1557 and the new presidential administration may precede a change in this trend.

In May 2024, the Biden administration issued a final rule implementing Section 1557.It reversed the rule put forth by the Trump administration four years prior, which had revised the Obama administration’s interpretation of the statute. The Biden administration’s final rule defined sex discrimination to include discrimination on the basis of gender identity and sexual orientation. Additionally, under the new rule, a wider swath of insurers and third-party administrators that receive federal financial assistance would be subject to Section 1557. 

However, in July 2024, a Mississippi District judge granted a nationwide injunction preventing the Department of Health and Human Services from enforcing the final rule’s prohibition of sex discrimination with respect to gender identity. Additionally, executive orders during the early days of the Trump administration, and guidance from the Department of Health and Human Services that followed, rescinded wide swaths of Biden-era guidance extending sex discrimination protections to include discrimination based on gender identity. It is not yet clear how the new administration’s position on Section 1557 will impact courts’ decision-making regarding insurer liability and the extent of sex discrimination provisions in relation to gender identity going forward. 

As the recent history of Section 1557 demonstrates, executive actions may influence the implementation of statutory antidiscrimination provisions, but do not change the law itself. While employers continue to face liability for discrimination towards employees seeking insurance coverage of gender-affirming care under Title VII, some protections remain on less certain ground as the United States enters a new presidential administration. 


Ting Cheung, Luke Lamberti, and Neha Sharma are with Sanford Heisler Sharp McKnight.

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New research shows coming out is still risky

A time of profound psychological vulnerability

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Coming out is often celebrated as a joyful milestone – a moment of truth, pride, and liberation. For many LGBTQ+ people, that’s exactly what it becomes. But new research I co-authored, published in the journal Pediatrics this month, shows that the period surrounding a young person’s first disclosure of their sexual identity is also a time of profound psychological vulnerability. It’s a fragile window we are not adequately protecting.

Using data from a national sample of lesbian, gay, and bisexual people, our study examined what happens in the years before and after someone comes out to a family member or a straight friend. We weren’t looking at broad lifetime trends or comparing LGBTQ+ youth to heterosexual peers. Instead, we looked within each person’s life. We wanted to understand how their own suicide risk changed around the moment they first disclosed who they are.

The results were unmistakable. In the year a person came out, their likelihood of having suicidal thoughts, developing a suicide plan, or attempting suicide increased sharply. Those increases were not small. Suicide planning rose by 10 to 12 percentage points. Suicide attempts increased by 6 percentage points. And the elevated risk didn’t fade quickly. It continued in the years that followed.

I want to be very clear about what these results mean: coming out itself is not the cause of suicidality. The act of disclosure does not harm young people. What harms them is the fear of rejection, the stress of navigating relationships that suddenly feel uncertain, and the emotional fallout when people they love respond with confusion, disapproval, or hostility.

In other words, young LGBTQ+ people are not inherently vulnerable. We make them vulnerable.

And this is happening even as our culture has grown more affirming, at least on the surface. One of the most surprising findings in our study was that younger generations showed larger increases in suicide risk around coming out compared to older generations. These are young people who grew up with marriage equality, LGBTQ+ celebrities, Pride flags in classrooms, and messaging that “it gets better.”

So why are they struggling more?

I think it’s, in part, because expectations have changed. When a young person grows up hearing that their community is increasingly accepted, they may expect support from family and friends. When that support does not come, or comes with hesitation, discomfort, or mixed messages, the disappointment is often devastating. Visibility without security can intensify vulnerability.

Compounding this vulnerability is the broader political environment. Over the last several years, LGBTQ+ youth have watched adults in positions of power debate their legitimacy, restrict their rights, and question their place in schools, sports, and even their own families. While our study did not analyze political factors directly, it is impossible to separate individual experiences from a climate that routinely targets LGBTQ+ young people in legislative hearings, news cycles, and social media.

When you’re 14 or 15 years old and deciding who to tell about your identity, the world around you matters.

But the most important takeaway from our study is this: support is important. The presence, or absence of family acceptance is typically one of the strongest predictors of whether young people thrive after coming out. Research consistently shows that when parents respond with love, curiosity, and affirmation, young people experience better mental health, stronger resilience, and lower suicide risk. When families reject their children, the consequences can be life-threatening.

Support doesn’t require perfect language or expertise. It requires listening. It requires pausing before reacting out of fear or unfamiliarity. It requires recognizing that a young person coming out is not asking you to change everything about your beliefs. They’re asking you to hold them through one of the most vulnerable moments of their life.

Schools, too, have an enormous role to play. LGBTQ+-inclusive curricula, student groups, and clear protections against harassment create safer environments for disclosure. 

Health care settings must also do better. Providers should routinely screen for mental health needs among LGBTQ+ youth, especially around the time of identity disclosure, and offer culturally competent care.

And as a community, we need to tell a more honest story about coming out. Yes, it can be liberating. Yes, it can be beautiful. But it can also be terrifying. Instead of pretending it’s always a rainbow-filled rite of passage, we must acknowledge its risks and surround young people with the support they deserve.

Coming out should not be a crisis moment. It should not be a turning point toward despair. If anything, it should be the beginning of a young person’s journey toward authenticity and joy.

That future is possible. But it depends on all of us – parents, educators, clinicians, policymakers, and LGBTQ+ adults ourselves – committing to make acceptance a daily practice.

Young LGBTQ+ people are watching. And in the moment they need us most, they must not fall into silence or struggle alone.


Harry Barbee, Ph.D., is an assistant professor at the Johns Hopkins Bloomberg School of Public Health. Their research and teaching focus on LGBTQ+ health, aging, and public policy. 

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Candidates should pledge to nominate LGBTQ judge to Supreme Court

Presidential, Senate hopefuls need to go on the record

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U.S. Supreme Court (Washington Blade photo by Michael Key)

As soon as the final votes are cast and counted and verified after the November 2026 elections are over, the 2028 presidential cycle will begin in earnest. Polls, financial aid requests, and volunteer opportunities ad infinitum will flood the public and personal media. There will be more issues than candidates in both parties. The rending of garments and mudslinging will be both interesting and maybe even amusing as citizens will watch how candidates react to each and every issue of the day.

There is one particular item that I am hoping each candidate will be asked whether in private or in public. If a Supreme Court vacancy occurs in your potential administration, will you nominate an open and qualified LGBTQ to join the remaining eight?

Other interest groups on both sides have made similar demands over the years and have had them honored. Is it not time that our voices are raised as well? There are several already sitting judges on both state and federal benches that have either been elected statewide or approved by the U.S. Senate.

Our communities are being utilized and abused on judicial menus. Enough already! Challenge each and every candidate, regardless of their party with our honest question and see if honest answers are given. By the way … no harm in asking the one-third of the U.S. Senate candidates too who will be on ballots. Looking forward to any candidate tap dancing!

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2026 elections will bring major changes to D.C. government

Mayor’s office, multiple Council seats up for grabs

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(Washington Blade file image by Aram Vartian)

Next year will be a banner year for elections in D.C. The mayor announced she will not run. Two Council members, Anita Bonds, At-large, and Brianne Nadeau, Ward 1, have announced they will not run. Waiting for Del. Norton to do the same, but even if she doesn’t, there will be a real race for that office. 

So far, Robert White, Council member at-large, and Brooke Pinto, Council member Ward 2, are among a host of others, who have announced. If one of these Council members should win, there would be a special election for their seat. If Kenyon McDuffie, Council member at-large, announces for mayor as a Democrat, which he is expected to do, he will have to resign his seat on the Council as he fills one of the non-Democratic seats there. Janeese George, Ward 4 Council member, announced she is running for mayor. Should she win, there would be a special election for her seat. Another special election could happen if Trayon White, Ward 8, is convicted of his alleged crimes, when he is brought to trial in January. Both the Council chair, and attorney general, have announced they are seeking reelection, along with a host of other offices that will be on the ballot.  

Many of the races could look like the one in Ward 1 where at least six people have already announced. They include three members of the LGBTQ community. It seems the current leader in that race is Jackie Reyes Yanes, a Latina activist, not a member of the LGBTQ community, who worked for Mayor Fenty as head of the Latino Affairs Office, and for Mayor Bowser as head of the Office of Community Affairs. About eight, including the two Council members, have already announced they are running for the delegate seat.

I am often asked by candidates for an endorsement. The reason being my years as a community, LGBTQ, and Democratic, activist; and my ability to endorse in my column in the Washington Blade. The only candidate I endorsed so far is Phil Mendelson, for Council chair. While he and I don’t always agree on everything, he’s a staunch supporter of the LGBTQ community, a rational person, and we need someone with a steady hand if there really are six new Council members, out of the 13. 

When candidates call, they realize I am a policy wonk. My unsolicited advice to all candidates is: Do more than talk in generalities, be specific and honest as to what you think you can do, if elected. Candidates running for a legislative office, should talk about what bills they will support, and then what new ones they will introduce. What are the first three things you will focus on for your constituents, if elected. If you are running against an incumbent, what do you think you can do differently than the person you hope to replace? For any new policies and programs you propose, if there is a cost, let constituents know how you intend to pay for them. Take the time to learn the city budget, and how money is currently being spent. The more information you have at your fingertips, the smarter you sound, and voters respect that, at least many do. If you are running for mayor, you need to develop a full platform, covering all the issues the city will face, something I have helped a number of previous mayors do. The next mayor will continue to have to deal with the felon in the White House. He/she/they will have to ensure he doesn’t try to eliminate home rule. The next mayor will have to understand how to walk a similar tightrope Mayor Bowser has balanced so effectively. 

Currently, the District provides lots of public money to candidates. If you decide to take it, know the details. The city makes it too easy to get. But while it is available, take advantage of it. One new variable in this election is the implementation of rank-choice voting. It will impact how you campaign. If you attack another candidate, you may not be the second, or even third, choice, of their strongest supporters. 

Each candidate needs a website. Aside from asking for donations and volunteers, it should have a robust issues section, biography, endorsements, and news. One example I share with candidates is my friend Zach Wahls’s website. He is running for United States Senate from Iowa. It is a comprehensive site, easy to navigate, with concise language, and great pictures. One thing to remember is that D.C. is overwhelmingly Democratic. Chances are the winner of the Democratic primary will win the general election. 

Potential candidates should read the DCBOE calendar. Petitions will be available at the Board of Elections on Jan. 23, with the primary on June 16th, and general election on Nov. 3. So, ready, set, go! 


Peter Rosenstein is a longtime LGBTQ rights and Democratic Party activist.

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