4th Circuit: Gender Identity Is A Protected Characteristic, Blocks State Coverage Bans In a landmark ruling, the 4th Circuit Court of Appeals has ruled that gender identity is a protected characteristic, and that Medicaid bans on treatments for gender dysphoria are unconstitutional. ERIN REED APR 29

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4th Circuit Court of Appeals, Richmond, VA - Taber Andrew Bain - CC BY 2.0 DEED Erin In The Morning is a reader-supported publication. To receive new posts and support my work, consider becoming a subscriber.

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The 4th U.S. Circuit Court of Appeals ruled Monday that transgender people are a protected class and that Medicaid bans on transgender 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 transgender 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 Court of Appeals declared that transgender exclusions were "obviously discriminatory" and were "in violation of the equal protection clause" of the U.S. Constitution, upholding lower court rulings that barred the discriminatory exclusions.

The 4th U.S. Circuit Court of Appeals ruling focused on two cases in states within its jurisdiction: North Carolina and West Virginia. In North Carolina, transgender 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:

4th Circuit rules against legal argument that transgender treatment bans do not discriminate against transgender 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 Supreme Court decision on discriminatory policies targeting transgender 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 transgender 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:

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 transgender care violate the Equal Protection Clause of the U.S. 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 transgender 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 transgender rights, with dozens of states filing amicus briefs in favor or against the protection of the equal process rights of transgender people. Twenty-one Republican states filed an amicus brief in favor of denying transgender people anti-discrimination protections in healthcare, and 17 Democratic states joined an amicus brief in support of the healthcare rights of transgender individuals.

Many Republican states are defending anti-trans laws that discriminate against transgender 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 transgender 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 transgender people. Earlier this month, the 4th U.S. Circuit Court of Appeals also reversed a sports ban in West Virginia, ruling that Title IX protects transgender student athletes. However, the U.S. Supreme Court recently narrowed a victory for transgender 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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