Federal Government
HHS official discusses agency’s proposed LGBTQ-inclusive nondiscrimination rule
Proposed regulation change published Tuesday
The U.S. Department of Health and Human Services published a Notice of Proposed Rulemaking on Tuesday for a new regulation that clarifies nondiscrimination rules on the basis of sexual orientation and gender identity.
“The department is doing all that it can to protect access to health and human services,” Melanie Fontes Rainer, director of HHS’s Office of Civil Rights, told the Washington Blade by phone on Tuesday.
“This proposed rule is a step in that effort,” she said.
Health programs administered by the agency are covered by the nondiscrimination rules in Section 1557 of the Affordable Care Act, Fontes Rainer said, so, “This rule is meant to get to that other slice of the pie that encompasses really important work at the Department of Human Services.”
Nondiscrimination, here, is a priority, “specifically nondiscrimination on the basis of sexual orientation and gender identity,” she said.
If finalized pursuant to the 60-day public comment period, HHS’s rule will apply to such programs as those administered by the “Administration for Children and Families, SAMHSA, and some other organizations within HHS that have grants,” Fontes Rainer said.
Examples include Head Start, which provides educational, health, nutritional and other services to low income children and their families.
The agency’s legal authority to enforce inclusive nondiscrimination rules was statutorily ordained by Congress, but clarified with the U.S. Supreme Court’s 2020 ruling in Bostock v. Clayton County, which “made clear that sexual orientation and gender identity were part of this protected sex based discrimination class,” Fontes Rainer said.
The decision helped to accelerate the Biden-Harris administration’s coordination of efforts across the federal government to shore up protections for LGBTQ Americans, she noted, beginning with the Justice Department and then the U.S. Department of Education and HHS.
Those agencies and federal courts have since made clear the law applies not just in the Title VII context — which covers nondiscrimination in employment, the legal question at issue in Bostock — but also “to other federal programs like Title IX,” Fontes Rainer said.
HHS is coordinating efforts with the White House, which last month unveiled a series of new actions to better protect LGBTQ Americans, including through programs administered by HHS, such as those targeting queer youth and their families.
Last June, Fontes Rainer noted, the administration announced that the department’s Administration for Children and Families would pursue a new rule making to “clarify that state child welfare agencies must ensure LGBTQI youth are treated in a safe and appropriate manner.”
The agency’s rule “is inclusive of some grants and services that are inclusive of homelessness services for LGBTQI youth,” Fontes Rainer said. “That’s certainly a part of it. And this grants rule is certainly a part of that effort in the Human Services context.”
“It’s really important right now to have the federal government be strong in the LGBTQI space, whether it’s healthcare, human services or some other service that the federal government provides and [also to] be very clear about what non discrimination means,” she said. “Because, you know, there there is a tsunami of these [anti-trans] healthcare bans across the country.”
According to the Human Rights Campaign, almost 30 percent of transgender youth in the U.S. live in places that have passed bans on gender affirming care, criminalizing healthcare interventions that are backed by every mainstream scientific and medical society.
“We’re seeing a shift right now, where there are a lot of healthcare bans,” Fontes Rainer said. “And, I think, ultimately, these are decisions that are going to be taken into litigation in various contexts, which we’re already seeing across the country.”
Meanwhile, on the federal level, Congressional Republicans are moving to add riders restricting access to healthcare for trans youth into must-pass appropriations bills. Asked to respond to these efforts, Fontes Rainer was quick to note that, “my job is not on the legislative front, here.”
At the same time, she said, when it comes to HHS’s proposed regulation, for “every single program and service we’ve identified, these [nondiscrimination] protections already exist in the law,” so the agency is therefore confident that “we are on good authority and legal footing here.”
While the regulation and its implementation would be new, Fontes Rainer said, HHS is acting under its statutory authority as established long ago by the legislature.
Policy carries real impact on people, families
Last month, HHS hosted a Pride Summit, where officials at the agency from Fontes Rainer to Assistant Secretary Adm. Rachel Levine and Secretary Xavier Becerra, along with other high ranking members of the Biden-Harris administration like White House Press Secretary Karine Jean-Pierre, spoke about the government’s work advancing rights and protections for the LGBTQ community.
At the event, Becerra dedicated a portion of his remarks to recounting discussions he had with LGBTQ families about how his agency can better serve their needs across the various health and human services programs that comprise its book of business.
Fontes Rainer told the Blade she has participated in many of these conversations, with and without the secretary. “I have made a point to visit with providers, advocates, parents and kids, in many of the states that either have passed or are seeking to pass bans on healthcare for trans youth,” she said.
“Every time I have these conversations, I feel emotional afterwards,” she said. “For a lot of these kids and families, you know, they’re not asking for much. They’re asking to go to the doctor. They’re asking to be treated with respect. They’re asking to have the appropriate pronouns used — things that are very basic.”
The circumstances vary, Fontes Rainer said. Some families have the resources to travel or even relocate to states that are committed to protecting their transgender residents’ access to healthcare.
Others, however, do not. Parents, she said, often “don’t know what they’re gonna do as their child is [forcibly] tapered off of medication, mid treatment” and many are unsure how to respond to the resulting impacts on their child’s mental health.
Fontes Rainer said she has also seen the impacts of legislative restrictions on the healthcare system. “I’ve talked to providers who tell me that they provide gender affirming care in a state where it’s not banned and it’s impossible to get appointments now, because they have so many people traveling there,” she said.
“These efforts by the Biden administration, while they don’t solve everything, they’re really important — both in being strong on the policy and what the law means, but also in being very clear to parents and families and doctors that we have your back,” Fontes Rainer said.
“I’ve been in rooms with the secretary where people, providers, you know, hug him and cry,” she said, “because they feel like it’s really important to have somebody that understands the law in this moment, and they feel like it’s important that, you know, from the secretary on up to the president of the United States, they have support from the Biden administration.”
Fontes Rainer told the Blade she is proud of HHS’s legacy of leadership on LGBTQ rights. With a ceremony last year, the agency became the first to raise the Progress Pride flag, which includes colors to represent Black and brown LGBTQ communities and incorporates the stripes of the transgender Pride flag.
“Now, this year, almost every single agency did that,” she said, adding that last month, “my husband and I put up a Pride Unity flag in our yard” too.
“Right now is not the time to be shy,” Fontes Rainer said. “Now is not the time to like go hide in a hole. Now is the time to be loud and vocal and use your power for good.”
Federal Government
US Census Bureau testing survey on LGBTQ households
Agency proposing questions about sexual orientation and gender identity
The U.S. Census Bureau is seeking public comment on a proposed test of sexual orientation and gender identity questions on the American Community Survey. The test would begin this summer and continue into next year.
The Census Bureau published the request as a Federal Register notice. In its press release the agency noted that the ACS is an ongoing survey that collects detailed housing and socioeconomic data. It allows the Census Bureau to provide timely and relevant housing and socioeconomic statistics, even for low levels of geography.
As part of the process for adding new questions to the ACS, the Census Bureau tests potential questions to evaluate the quality of the data collected.
The Census Bureau proposes testing questions about sexual orientation and gender identity to meet the needs of other federal agencies that have expressed interest in or have identified legal uses for the information, such as enforcing civil rights and equal employment measures.
The test would follow the protocols of the actual ACS — with one person asked to respond to the survey on behalf of the entire household. These particular questions are asked about people 15 years of age or older. Households are invited to respond to the survey online, by paper questionnaire or by phone.
The current Federal Register notice gives the public a final opportunity to provide feedback before the Census Bureau submits its recommendations to the Office of Management and Budget for approval. The public may provide feedback through May 30 online.
Federal Government
Republican state AGs challenge Biden administration’s revised Title IX policies
New rules protect LGBTQ students from discrimination
Four Republicans state attorneys general have sued the Biden-Harris administration over the U.S. Department of Education’s new Title IX policies that were finalized April 19 and carry anti-discrimination protections for LGBTQ students in public schools.
The lawsuit filed on Tuesday, which is led by the attorneys general of Kentucky and Tennessee, follows a pair of legal challenges from nine Republican states on Monday — all contesting the administration’s interpretation that sex-based discrimination under the statute also covers that which is based on the victim’s sexual orientation or gender identity.
The administration also rolled back Trump-era rules governing how schools must respond to allegations of sexual harassment and sexual assault, which were widely perceived as biased in favor of the interests of those who are accused.
“The U.S. Department of Education has no authority to let boys into girls’ locker rooms,” Tennessee Attorney General Jonathan Skrmetti said in a statement. “In the decades since its adoption, Title IX has been universally understood to protect the privacy and safety of women in private spaces like locker rooms and bathrooms.”
“Florida is suing the Biden administration over its unlawful Title IX changes,” Florida Gov. Ron DeSantis wrote on social media. “Biden is abusing his constitutional authority to push an ideological agenda that harms women and girls and conflicts with the truth.”
After announcing the finalization of the department’s new rules, Education Secretary Miguel Cardona told reporters, “These regulations make it crystal clear that everyone can access schools that are safe, welcoming and that respect their rights.”
The new rule does not provide guidance on whether schools must allow transgender students to play on sports teams corresponding with their gender identity to comply with Title IX, a question that is addressed in a separate rule proposed by the agency in April.
LGBTQ and civil rights advocacy groups praised the changes. Lambda Legal issued a statement arguing the new rule “protects LGBTQ+ students from discrimination and other abuse,” adding that it “appropriately underscores that Title IX’s civil rights protections clearly cover LGBTQ+ students, as well as survivors and pregnant and parenting students across race and gender identity.”
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 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 “apply to everyone, not just transgender people.” 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 “applying to straight, gay, lesbian, and bisexual people equally,” 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, “gender 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.” 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 “XX chromosomes” and “XY chromosomes” 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 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. Twenty-one Republican states filed an amicus brief in favor of denying trans people anti-discrimination protections in healthcare, and 17 Democratic states 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 Carolina already have gender-affirming care bans for trans youth in place, and 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, the Supreme Court recently narrowed 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, “The 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.”
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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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