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Adm. Levine celebrates trans joy on Transgender Day of Visibility

‘We continue to live a life of joy in the face of adversity’

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Dr. Rachel Levine (Washington Blade photo by Michael Key)

The day after Sunday’s Transgender Day of Visibility observance, the Washington Blade connected with Adm. Rachel Levine, a pediatrician serving as assistant secretary of health at the U.S. Department of Health and Human Services.

“Trans joy means authenticity and being comfortable in your own skin and being able to be who you are,” said Levine, who is the highest-ranking transgender official in U.S. history.

“With my transition, I was able to be my authentic self,” she remembers. “At that time, I was still a professor at the Penn State College of Medicine, and an attending physician at the Penn State Hershey Medical Center in pediatrics and adolescent medicine, but then I had this unique opportunity to become the physician general of Pennsylvania for then-Gov. Tom Wolf, and then two and a half years later to become the Secretary of Health.”

“So it has been a tremendous journey, which has been very rewarding,” Levine said, adding that it has been “an honor” to work for the Biden-Harris administration under HHS Secretary Xavier Becerra ā€” all allies of trans, nonbinary, and gender expansive folks and of the LGBTQ community more broadly.

Levine recounted how Transportation Secretary Pete Buttigieg, himself the first openly gay Senate-confirmed Cabinet secretary, had singled her out as one of the administration’s other high-ranking LGBTQ appointees during a 2021 Pride celebration at the White House.

At that moment, President Joe Biden “looked me in the eye and, you know, kind of gestured for me to stand up for the applause,” she remembered, and “I thought that that was just truly meaningful and shows his compassion and his attention to the people working for him and his administration.”

At the same time, Levine’s tenure has, unfortunately, come with bigoted attacks from the likes of U.S. Rep. Marjorie Taylor Greene (R-Ga.), but she said part of trans joy means “we fight hate with love, and we continue to live a life of joy in the face of adversity.”

“For me personally, I am able to compartmentalize those attacks,” she said. “You know, and I’ve learned this in my clinical work as a pediatrician, where, if you are in the emergency department or in the office or in the hospital and you have a very sick patient in front of you, you have to be able to function as a professional and compartmentalize your feelings and then be able to bring them out later and process them.”

Levine explained, “And so it’s the same thing so that if I am attacked, I’m able to compartmentalize any emotions about that and then I work that through with my friends and my family.”

“In addition, though, I’ve also learned the art of sublimation where, you know, the more people attack me, then I’m able to turn that around and it serves as motivation for me to work harder and advocate more.”

Rather than herself, Levine said, “What I worry about are the most vulnerable in our community, who I think it can be very challenging for, particularly in these times, to vulnerable transgender and nonbinary youth, their families, and even their medical providers in many states across the country.”

Levine shared her thoughts about the public’s eroding faith in science, medicine, and institutional expertise ā€” themes that often arise in the context of debates over gender affirming healthcare, as guideline-directed and medically necessary interventions that are supported by every mainstream medical society have come under fire from right-wing politicians.

“There is a lot of misinformation and overt disinformation about transgender medicine,” she said. “You know, transgender medicine is an evidence-based standard of care, which continues to benefit from continued research and evolution from, you know, standards 10 or more years ago to the current standards now published.”

Levine added, “Transgender medicine is absolutely necessary for transgender and gender diverse people including youth ā€” and transgender medicine is medical care, but it’s also mental health care, and it’s literally suicide prevention care” that has “been shown in study after study to improve the quality of life and can literally save lives.”

Transgender medicine “for young people [is often] conducted at many of our nation’s expert children’s hospitals,” Levine said. “Let me put it this way: if you have a child with a fever, you would take your child, perhaps, to a pediatrician. If they had severe diabetes, you would take them to a pediatric endocrinologist. If they had a mental health condition, you might take them to a child psychiatrist or psychologist.”

“So,” she said, “if you have a child with gender questions or gender issues then you’re going to take them to the pediatric and adolescent gender specialist, and it’s often a team ā€” including the same endocrinologist and it might be the same psychiatrist or psychologist.”

“You’re not going to think, ‘oh, I’m going to call my state legislator.'”

Nevertheless, Levine said, “These issues have been politicized for political and ideological reasons” over the objections of physicians like Jesse Ehrenfeld, president of the American Medical Association, who during a panel discussion with Levine for the PFLAG National convention in November, agreed that politicians should not get between patients, their families, and their healthcare providers.

“We see other areas where there’s misinformation and disinformation,” Levine said, perhaps partly a consequence of the politicization of the public health response to the COVID pandemic, which has led to vaccine hesitancy for COVID as well as childhood immunizations.

Ultimately, she said, “physicians and other medical and public health professionals are trying to help people,” which is “what I tried to do when I was in academic medicine” where “I really worked to help people, the patients and families that I saw as well as teaching as well as clinical research ā€” and I think, overall, that’s what most physicians and medical professionals and public health professionals are doing.”

Exciting work ahead at HHS

When it comes to the work in which her agency is engaged, Levine said “health equity is fundamental to everything that we’re doing at HHS under Secretary Becerra and so many of our key policy initiatives relate to health equity.”

“So,” she said, “that includes health equity for the LGBTQI+ community, working to end the HIV epidemic in the United States with a focus on health equity, working to safeguard LGBTQI+ youth from the harms of conversion therapy, promoting data equity for our community, SAMHSA’s work on on conversion therapy, ARC’s work in terms of a sample patient intake form to improve the patient care experience for LGBTQI+ people, and more.”

“We have an office of climate change and health equity with a sister office of environmental justice,” Levine added. “We’re working on health equity in terms of reproductive health and reproductive rights, in the face of the Dobbs decision,” which revoked the constitutional right to abortion.

“We’re working in terms of health equity in regards to food and nutrition,” she said, “in terms of long COVID, and more.”

As with many initiatives under Biden’s presidency, “There is a tremendous emphasis on breaking down silos within divisions at HHS and between departments,” Levine said.

She shared a few examples: “One is our work on long COVID. We have an office of long COVID research and practice, which is really working across the administration with that whole of government approach. Another is in terms of our work on climate change and health equity with the EPA, and the White House Climate Council.”

“And then another actually would be our work on syphilis,” Levine said. “We run ā€” and I chair ā€” a syphilis and congenital syphilis federal government task force, which includes all the divisions at HHS, but also includes the VA and the Department of Defense, trying to address the significant increases in syphilis and congenital syphilis that we’ve seen the United States.”

And then, “Another example within the LGBTQ space is a global interagency action plan about conversion therapy, which includes HHS, the Department of State, the Department of the Treasury, and USAID.”

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Federal Government

US Census Bureau testing survey on LGBTQ households

Agency proposing questions about sexual orientation and gender identity

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The U.S. Census Bureau headquarters in Suitland, Md. (Photo courtesy of the U.S. Census Bureau)

The U.S. Census BureauĀ 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 ā€” 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.

TheĀ current Federal Register noticeĀ 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 30Ā online.

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Federal Government

Republican state AGs challenge Biden administration’s revised Title IX policies

New rules protect LGBTQ students from discrimination

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U.S. Secretary of Education Miguel Cardona (Screen capture: AP/YouTube)

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 ā€” 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.

ā€œThe U.S. Department of Education has no authority to let boys into girlsā€™ locker rooms,ā€Ā Tennessee Attorney General Jonathan Skrmetti said in a statement. ā€œIn 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, ā€œThese 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 ā€œprotects LGBTQ+ students from discrimination and other abuse,ā€Ā adding that it “appropriately underscores that Title IXā€™s civil rights protections clearly cover LGBTQ+ students, as well as survivors and pregnant and parenting students across race and gender identity.”

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Federal Government

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 stateā€™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 stateā€™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 Actā€™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 Circuitā€™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 Carolinaā€™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 courtā€™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 ā€¦ 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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