Transgender nurse sues over exclusion of health coverage for gender dysphoria

The American Civil Liberties Union has filed a lawsuit on behalf of a nurse whose employer, Dignity Health, purportedly violated federal law by denying transgender employees health insurance coverage for medically necessary gender transition-related health care. The plaintiff, a transgender man who is an operating room nurse at Chandler Regional Medical Center in Chandler, Arizona, claims that Dignity Health denied him insurance coverage for gender dysphoria treatment, and as a result, he was forced to pay thousands of dollars out of pocket.

Dignity’s Health Plan “has a categorical exclusion of ‘Treatment, drugs, medicines, services and supplies for, or leading to, sex transformation surgery,’” according to the complaint. Dignity Health’s refusal to provide insurance coverage for medically necessary transition-related care allegedly discriminates on the basis of sex, in violation of Title VII and the Patient Protection and Affordable Care Act. The nurse is looking for the same health benefits that other, non-transgender Dignity Health employees receive—coverage for medically necessary treatments.

Gender dysphoria. According to the complaint, gender dysphoria is a serious medical condition that is codified in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) and the International Classification of Diseases (IC-10). Under the widely accepted standards of care (published by the World Professional Association for Transgender Health—WPATH) for treating gender dysphoria, medically necessary treatment may require “medical steps to affirm one’s gender identity and help an individual transition from living as one gender to another.” This “transition-related care” may include hormone therapy, surgery (so-called sex reassignment surgery) and other medical services “that align individuals’ bodies with their gender identities.” Medical treatment varies based on the individualized needs of the person.

“According to every major medical organization and the overwhelming consensus among medical experts, treatments for gender dysphoria, including surgical procedures, are effective, safe, and medically necessary when clinically indicated to alleviate gender dysphoria,” the complaint states. While in the past public and private insurance companies have excluded coverage for transition-related care based on the erroneous assumption that such treatments were cosmetic or experimental, today, “the medical consensus recognizes that such discriminatory exclusions of transition-related healthcare have no basis in medical science,” the plaintiff alleges.

Exclusion of care. Dignity Health provides its employees with health care through a self-funded plan administered by United Medical Resources, a wholly owned subsidiary of United Healthcare. According to the complaint, United Healthcare has adopted policy guidelines for coverage of medically necessary treatments for gender dysphoria in accordance with the WPATH standards of care, including “continuous hormone replacement therapy, complete hysterectomy, orchiectomy, penectomy, vaginoplasty, vaginectomy, clitoroplasty, labiaplasty, salpingo-oophorectomy, metoidioplasty, scrotoplasty, urethroplasty, placement of testicular prosthesis, phalloplasty, thyroid chondroplasty, bilateral mastectomy, and augmentation mammoplasty.”

The plaintiff alleges that because the Dignity Health Plan “categorically excludes all coverage related to ‘sex transformation surgery,’” it fails to cover “any of the medically necessary treatments for gender dysphoria that would be covered as medically necessary under United Healthcare’s coverage determination guidelines.” Not only has the plaintiff been forced to pay thousands for of dollars out of his own pocket for medically necessary care—including a double mastectomy—because it was categorically excluded from his employer’s health plan, he has also been forced to forego some medically necessary care in its entirety.

Personality disorder? In response to the nurse’s EEOC discrimination charge, Dignity Health purportedly claimed that the health care exclusion for gender dysphoria was not discriminatory because benefits under the plan are not provided for “any personality disorders, including sexual/gender identity disorders and behavior and impulse control disorders.”

According to complaint, though, the medical community does not consider gender dysphoria to be a personality disorder.

Bias based on transgender status, gender nonconformity. The complaint asserts Dignity Health has violated the prohibitions in Title VII and Section 1557 of the Affordable Care Act against discrimination on the basis of sex. The exclusion of medically necessary care related to “sex transformation surgery,” according to the complaint, amounts to discrimination based on transgender status and gender nonconformity in violation of both statutes. The plaintiff is seeking, among other things, declaratory and injunctive relief, as well as consequential and punitive damages.

“Every major medical association has affirmed that transition-related health care for transgender people is medically necessary,” Josh Block, an attorney with the ACLU LGBT & HIV Project, said in a statement. “Under Title VII and the Affordable Care Act, these sorts of discriminatory insurance provisions are illegal in all 50 states.”

SOURCE: Robinson v. Dignity Health, filed in the Northern District of California, No. 3:16-cv-03035, June 6, 2016.

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