4th Circuit Rules That States Can Compel Trans Adults To "Appreciate Their Sex" Via Care Bans
They ruled that states "encouraging citizens to appreciate their sex" through care bans is a constitutional goal, affirming West Virginia's Medicaid ban for trans adults.
On Tuesday, an all-Republican and mostly Trump-appointed panel of the Fourth Circuit Court of Appeals ruled that states can exclude gender-affirming surgery from Medicaid coverage, allowing West Virginia's exclusion to return to full effect. In doing so, the panel extended the Supreme Court's decision in Skrmetti—which held that transgender youth care bans were constitutional—to transgender adults, the first federal appeals court in the country to do so, and directly states that adult care bans are legal. Perhaps even more troubling, the judges declared that transgender adult care was "dangerous," and that it is rational for a state to restrict access to such care in order to "encourage citizens to appreciate their sex." The ruling effectively reversed a previous en banc decision by the same circuit and established precedent for a wave of new laws targeting transgender adults—just weeks after Heritage Foundation president Kevin Roberts declared on a podcast that the solution to transgender adult care was to "outlaw it."
“It is not irrational for a legislature to forgo Medicaid coverage of arguably ineffective and dangerous procedures and allocate its limited resources to covering other treatments. What’s more, States may legitimately recognize and “celebrat[e]” the “inherent differences between men and women.” Virginia, 518 U.S. at 533 (internal quotation marks omitted). And it is not irrational for a legislature to encourage citizens “to appreciate their sex” and not “become disdainful of their sex” by refusing to fund experimental procedures that may have the opposite effect. Skrmetti, 605 U.S. at 516–17,” wrote the justices, endorsing that “encouraging citizens to appreciate their sex” is now a proper and constitutional aim.
The court also took a significant step toward ruling that laws targeting transgender adult care would be constitutional. In a footnote, the court states, "While Skrmetti involved sex-change treatments for minors, disagreement among experts about the efficacy and necessity of transgender surgeries extends to treatment of gender dysphoria in adults." This claim is contradicted by the medical literature—multiple studies have confirmed the positive impact of gender-affirming surgeries for transgender people, including a 40-year follow-up study that found high patient satisfaction, improved dysphoria, and reduced mental health comorbidities with no reported patient regret. Nevertheless, a broader issue is at play: the Fourth Circuit appears to be wholeheartedly endorsing the idea that restrictions on transgender adults' access to care are constitutional.
In issuing its ruling, the court cites Skrmetti over 70 times. Skrmetti held that gender-affirming care bans for minors were not discriminatory because they hinged on a diagnosis of gender dysphoria and age, not on transgender status or sex. This reasoning was fiercely contested by the three dissenting justices and by multiple lower courts, which found that discriminating against a condition experienced exclusively by transgender people is inseparable from discriminating against transgender people themselves. But this ruling goes further than Skrmetti ever did. Skrmetti was explicitly about minors. The Fourth Circuit applies the same framework to adult care. The opinion even states outright: “If a State can reasonably ban it, of course a State can reasonably refuse to pay for it“—a sentence that reads less like a Medicaid ruling and more like a roadmap for legislatures to consider outright adult care bans.
The court’s reasoning relies on a symmetry that collapses under scrutiny: gender-affirming care for gender dysphoria is banned equally for transgender and cisgender people, the court reasons, so no one is being singled out. But cisgender people do not seek gender-affirming care for gender dysphoria. The “equality” is entirely theoretical. Justice Sotomayor flagged this exact problem in her Skrmetti dissent, drawing a parallel to Loving v. Virginia—the landmark case striking down interracial marriage bans. Virginia had argued its anti-miscegenation law was not racially discriminatory because it banned interracial marriage equally for Black and white citizens alike. The Supreme Court rejected that reasoning in 1967, yet the Fourth Circuit now embraces its mirror image: a ban that targets a medical need unique to transgender people is not discriminatory because it technically applies to everyone. It is the equivalent of taxing yarmulkes and claiming the tax is not antisemitic because anyone, Jewish or not, who wears a yarmulke must pay.
What's worse, the precedent in this decision can be weaponized far beyond Medicaid. If it is not unconstitutional to "encourage citizens to appreciate their sex," the implications extend to virtually every area of transgender life. Are gender marker bans on IDs legal because carrying correct documents could "discourage" transgender people from "appreciating their sex?" Are drag bans and bans on cross-gender clothing legal because the state has an interest in encouraging the appreciation of sex? Could a state compel transgender people into conversion therapy, reasoning that it is not discriminatory because it targets a medical diagnosis rather than transgender status—and that the goal is simply to "encourage them to appreciate their sex?" The implications are terrifying for transgender people, and the court's language provides no limiting principle to prevent any of these outcomes.
The ruling also comes just weeks after Heritage Foundation president Kevin Roberts declared on the PBD podcast that adult care bans would be the organization's next target. "There does seem to be a mounting body of evidence that suggests a correlation between that surgery at any age, mental health issues, and increasingly, although we're running the numbers on this at Heritage, acts of violence," Roberts said. When host Patrick Bet-David asked how to address it, Roberts responded: "You outlaw it." When pressed on how, Roberts described a strategy of "radical incrementalism"—taking "a quarter of the enchilada" at a time until adult care is eliminated entirely. This court ruling hands Heritage exactly the legal framework it needs to execute that strategy.
The ruling is likely to be cited across the country as states push new anti-transgender legislation. It effectively overturns the Fourth Circuit's own 2024 en banc decision in Kadel v. Folwell, in which the full court ruled 8-6 that excluding gender-affirming care from coverage was unconstitutional. At least seven other states face active lawsuits over similar Medicaid exclusions, and the Ninth Circuit is currently reconsidering M.H. v. Hamso—a parallel Medicaid coverage case also sent back after Skrmetti. If the Ninth Circuit follows the Fourth, the appellate consensus solidifies. If it splits, it could tee up a Supreme Court case on adult care directly.Meanwhile, Puerto Rico banned adult trans healthcare to 21 years old, and Trump has set the age at 19 via executive orders, including some adults. The legal architecture for eliminating transgender adult healthcare is being assembled in plain sight, and this ruling will make it easier for states to do just that.
You can see the full 4th Circuit ruling here:
This is the worst court decision I have read from an appellate circuit on a trans issue in recent years. Horrifying decision.
So either we're horrific perverts or dumb children who can't make our own decisions? Funny how that works isn't it?