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11th Circuit Rules Trans Health Insurance Exclusions Violate Civil Rights Act

With the ruling, a significant precedent is building to protect trans employees against health insurance restrictions.

A protester holds a sign reading "Oh no! Did I confuse your Cis-tem?" during an outdoor protest in Bremen, Germany, on November 19, 2022.

On Monday, the 11th Circuit Court of Appeals ruled that transgender health insurance exclusions violate Title VII of the Civil Rights Act. The case was brought by a transgender employee of the Houston County Sheriff’s Office in Georgia who was denied coverage for gender-affirming surgery. The employee sued in 2019, and after a protracted lawsuit, won at the district court level. Now, with this 11th Circuit Court ruling in favor of transgender employees, a significant precedent is building to protect transgender employees against health insurance restrictions that deny them the ability to get gender-affirming care.

The employee in question first transitioned in 2017. After informing Sheriff Cullen Talton at the Houston County Sheriff’s Office of her decision to transition, she was told that he “does not believe in” being transgender, but that she would be allowed to keep her job. However, when it came time to obtain gender-affirming surgery, significant controversy erupted: her claims were denied. When she filed a lawsuit to have her surgery covered, the sheriff’s office and county fought against her right to equitable health care coverage.

Since then, the county has spent incredible amounts of money denying the plaintiff her care. As of 2023, Houston County, Georgia, had spent $1,188,701 fighting against providing health care coverage for the transgender plaintiff. This is significant: ProPublica reports that it is over three times the county’s annual physical and mental health budget. Importantly, no other employee has requested coverage for gender-affirming surgery, so fighting against coverage has significantly cost the county far more than it would have gained by simply providing the employee with that coverage.

Ultimately, a lower court ruled in her favor, stating that such exclusions violate Title VII of the Civil Rights Act. In the decision, the judge stated, “the implication of Bostock is clear … discrimination on the basis of transgender status is discrimination on the basis of sex and is a violation of Title VII.” The judge then ruled that the exclusion was facially discriminatory and violates Title VII. In doing so, he ordered that the county must drop such exclusions. The plaintiff was also awarded $60,000 following the ruling.

The county appealed the ruling to the 11th Circuit Court of Appeals, which seemed primed to potentially reverse it. Recently, the 11th Circuit has issued harsh rulings toward transgender individuals, such as a ruling that gender-affirming care bans for transgender youth do not violate Equal Protection and Due Process rights. In this particular case, though, the court considered a different argument: whether such exclusions on transgender insurance coverage violate employment law under the Civil Rights Act. The 11th Circuit concluded that they did: “The exclusion is a blanket denial of coverage for gender-affirming surgery … because transgender persons are the only plan participants who qualify for gender-affirming surgery, the plan denies health care coverage based on transgender status.”

In making its decision, the court referenced two recent developments that may change the legal landscape for transgender people. In one footnote, the court mentioned Kadel v. Folwell, a case just decided in the 4th Circuit Court of Appeals, with the court ruling that discrimination against transgender health care violates the Equal Protection Clause. Though it does not reference the case elsewhere, the 11th Circuit used similar legal arguments: that you cannot circumvent discrimination cases by discriminating by proxy. In this case, like in the Kadel case, the judge ruled that discriminating against transgender health care is also discriminating against transgender status. The judge ruled that the defendant’s “sex is inextricably tied to the denial of coverage for gender-affirming surgery,” and thus, one cannot circumvent discrimination statutes by claiming they are only discriminating against a procedure and not a category of people.

The court also referenced new Title VII guidance from the Biden administration in a footnote when making its decision that exclusions violate those regulations. On April 29, the U.S. Equal Employment Opportunity Commission issued updated guidance stating that Title VII protections include protections on gender identity. Although the guidance does not have the force of law, “numerous courts, including the Supreme Court, have said: Because these guidelines are based on the expertise and careful reasoning of the agency that’s charged with enforcing anti-discrimination laws, they’re to be given deference by the courts,” Christopher Ho, the director of the National Origin and Immigrants’ Rights Program at Legal Aid at Work, stated in an interview with the Washington Post at the time of the guidelines’ release. Now, it appears that a major court, which has ruled against transgender rights in the past, has indeed given those guidelines some credit in their ruling.

The ruling is significant and will likely be one of the many rulings referenced whenever such cases eventually reach the Supreme Court. Multiple courts have ruled in favor of transgender people and their health care, but some significant courts, including in a recent decision by the 11th Circuit Court on health care for transgender youth, have ruled against such legal protections. It is likely that this decision will be cited favorably in many other court cases in the coming months.

This piece was republished with permission from Erin In The Morning.