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Trans residents sue Florida over ban on gender-affirming Medicaid care

Under a rule approved by Florida health officials last month, trans patients no longer can use Medicaid to pay for their gender-affirming care

(iStock; Carl Juste/Miami Herald/ AP/Washington Post illustration)
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When August Dekker celebrated his 28th birthday in June, it was a moment of affirmation and euphoria, he said.

The Hernando County, Fla., resident went to the beach with his family. It was a perfect afternoon, he said: They sipped mojitos, played in the water, made “a very bad sand castle,” and ate mac and cheese at a seaside restaurant. But the highlight of the day was a simple one — it was the first time he could take his shirt off in public and feel comfortable.

Dekker, who is transgender, had undergone chest surgery three months before.

Although Dekker had been taking testosterone injections for years, he said he decided to get top surgery because of the shifting political and social climate — as more states, including Florida, try to roll back access to gender-affirming care.

“I was afraid that if I didn’t get the ball rolling, that I would not be able to have surgery covered in the future,” he said. Because Dekker receives disability benefits — they are his only source of income — he was able to pay for the procedure through Medicaid, just as he has done for his hormone therapy.

But according to a rule approved by Florida health officials last month, Dekker and other trans patients no longer can use Medicaid to pay for their gender-affirming care.

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Dekker and three other trans Floridians are fighting back against the policy.

On Wednesday morning, LGBTQ and health advocacy groups filed a lawsuit in the U.S. District Court for the Northern District of Florida challenging the state’s new Medicaid exclusion. The complaint was filed on behalf of Dekker and Brit Rothstein, as well as two minors, Susan Doe (represented by parents John and Jane Doe) and K.F. (represented by mother Jade Ladue). The lawsuit argues that Florida’s policy, which went into effect last month, violates the plaintiffs’ constitutional rights and federal nondiscrimination statutes, because it categorically denies them treatment on the basis of their gender identity.

Brock Juarez, a spokesperson for the Agency for Health Care Administration, which is named in the lawsuit, defended the policy.

“Under our rules, only treatments that are found to be safe, effective, and that meet medical necessity criteria may be covered,” Juarez wrote in an email. “That is precisely what the Agency has done here.”

The state’s Medicaid exclusion occurs amid a larger effort, in Florida and elsewhere, to roll back access to gender transition care, particularly for trans youths. Conservative lawmakers argue that these policies are meant to protect children and families from harmful procedures they may later regret.

Gender-affirming care is “critical and lifesaving” for transgender Floridians, said Simone Chriss, the director of the Transgender Rights Initiative at the Southern Legal Counsel, one of the groups involved in the lawsuit.

“It’s important that we dispel the myths that allow people to believe that bans like this are protecting anyone,” Chriss said. “They are harming people and denying them access to care that has been deemed medically necessary for them.”

Omar Gonzalez-Pagan of Lambda Legal, an LGBTQ civil rights organization also challenging the rule, added that the procedures banned for trans patients are still covered for cisgender Medicaid patients using them to treat other conditions.

Across the country, advocacy groups are pushing back against such policies. In Alabama and Arkansas, bans on gender-affirming care have been temporarily blocked by federal courts amid legal challenges.

Gender-affirming care can, but does not always, include medical interventions such as hormone replacement therapy, chest surgery or voice therapy. Although conservative politicians — including Florida Gov. Ron DeSantis (R) — often refer to genital surgeries being performed on minors, these procedures are not recommended for patients younger than 18.

While just over half of states have expanded Medicaid protections for gender-affirming care, Florida is among nine states that explicitly exclude residents from using Medicaid to pay for it.

The rule came after a report in June by the state’s Agency for Health Care Administration that claims services for the treatment of gender dysphoria are “not consistent with widely accepted professional medical standards,” and are “experimental and investigational with the potential for harmful long term affects.”

Medical professionals told The Washington Post last month that the agency’s actions are highly unusual and concerning.

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The country’s largest medical organizations, including the American Academy of Pediatrics, recommend gender-affirming care to help treat minors experiencing psychological distress because their biological sex and gender identity do not align, a condition known as gender dysphoria. In April, 300 medical providers in the state wrote an open letter in the Tampa Bay Times criticizing a state memo that advised doctors not to give gender-affirming care to minors.

“Florida was really the first state to come for the throat of the medical evidence behind gender-affirming care, to create this false narrative that there is not sufficient evidence to support the benefits,” said Meredithe McNamara, an assistant professor at Yale’s School of Medicine who was a part of a team of researchers that recently reviewed the AHCA report.

Brock Juarez, a spokesperson for the AHCA, told The Washington Post in August that the agency conducted “a very thorough process, and our in-depth work and findings really speak for itself.”

As the state’s medical board considers more rules restricting trans Floridians’ ability to receive gender-affirming care, patients who rely on Medicaid are scrambling to figure out how they can pay for their upcoming treatments and not disrupt the care on which they have come to depend.

Among those exploring alternative funding are John and Jane Doe, who joined the lawsuit on behalf of their 12-year-old daughter, “Susan.” The couple, who declined to be named to protect their child’s right to privacy, adopted Susan, as well as their eldest son, out of medical foster care, which makes the children eligible for Medicaid coverage until they turn 18.

As a young child, Susan would come home from school and immediately change into “princess dresses,” according to the lawsuit. Eventually, she socially transitioned — changing her name, hair and pronouns to align with her gender identity.

Along the way, the family began working with a team of doctors — including mental health specialists, primary-care physicians and a pediatric endocrinologist — to support Susan’s medical needs. On their recommendation, she recently began taking Lupron, a puberty blocker that needs to be administered every three months.

According to the complaint, her next injection is scheduled for October, but without Medicaid coverage, the family may be forced to pay out of pocket for the medication, which they said costs about $11,000 for a single shot.

They would have to go into debt to afford Susan’s care, even if they are able to move her under her father’s health-care plan. Switching insurance plans also means that Susan could be cut off from her long-term health-care providers, including those seeing her for other conditions.

It’s a “cruel” position to be put in, Susan’s father said in an interview.

Dekker, the trans man receiving disability benefits, said he fears for his safety in a way he had not before.

The political attacks have triggered increased harassment and violence against trans people in Florida, he said. But Dekker also remembers what it felt like to be without hormone therapy. He was depressed and reclusive, showering with the lights off so he would not have to see his body, he said. At times, he was suicidal.

That’s why it was important to him to step forward and challenge his home state, Dekker said: “The thought of going back to that ghost person that I was. … I don’t want to become that person again.”