Obama Judge Rules Medicaid Must Pay for Transgender Sex Reassignment Surgery

An Obama-appointed federal judge is forcing Wisconsin taxpayers to provide costly sex reassignment surgery and hormonal procedures for low-income transgender residents who get free medical care from the government. In a recently issued ruling U.S. District Judge William M. Conley writes that Medicaid, the publicly funded insurance that covers 65.7 million poor people, cannot deny the medical treatment needs of those suffering from “gender dysphoria.” Officials estimate it will cost up to $1.2 million annually to provide transgender Medicaid recipients in the Badger State with treatments such as “gender confirmation” surgery, including elective mastectomies, hysterectomies, genital reconstruction and breast augmentation. The intricate operations are typically done by plastic surgeons.

The ruling culminates a lawsuit filed more than a year ago by two transgender Wisconsinites, who accuse the federal and state-funded insurance program of providing them with disparate and inferior health care on the basis of sex. Cody Flack of Green Bay and Sara Makenzie of Baraboo say they suffer from severe gender dysphoria that requires costly surgery. Flack, a woman, claims to be ashamed of her breasts and wants to have them surgically removed as she transitions into a man’s body. To make a case for the government to pay for her surgery, she claims that she engages in “binding,” which flattens her breasts and causes sores, skin irritation and respiratory distress. Flack also has difficulty binding her breasts due to a disability, according to court documents. Makenzie, a man who legally changed his name to Sara and wears women’s clothing, says his “male-appearing genitalia” causes him “great distress” and negatively affects his sexuality and social life. Showering and seeing his body in a mirror is “painful,” court records state, and Makenzie fears someone will be able to see his “male genitals” through his clothing.

Last summer Judge Conley issued a preliminary injunction ordering Wisconsin to cover sex reassignment surgery for Flack and Makenzie while state health officials appealed. The permanent ruling directing the state-federal insurance for the poor to pay for all gender confirmation operations in the state was issued last week. To lay the foundation, Conley writes in the injunction that gender dysphoria is a serious medical condition, which if left untreated can cause adverse symptoms. “As a group, transgender individuals have been subjected to harassment and discrimination in virtually every aspect of their lives, including in housing, employment, education, and health care,” according to the document. “Their own families, acquaintances and larger communities can be sources of harassment. For some transgender individuals, though certainly not all, the dissonance between their gender identity and their naturally assigned sex can manifest itself in the form of gender dysphoria, a serious medical condition recognized by both sides’ experts and the larger medical community as a whole.”

Though Medicaid initially denied Flack’s chest reconstructive surgery, it was eventually completed at taxpayer expense after the judge’s injunction. A plastic surgeon performed a double mastectomy and male chest construction last fall. “Following the surgery, Cody’s gender dysphoria was greatly diminished,” according to Conley’s final ruling, because his “outward appearance matched his male gender” and he “would no longer be misgendered because of his breasts.” Makenzie got a bilateral orchiectomy and vaginoplasty to create “female appearing external genitalia” after the judge determined that the surgeries are medically necessary. Because Medicaid refused to cover chest reconstruction surgery prior to the lawsuit, Makenzie obtained a personal loan to pay a plastic surgeon at the University of Wisconsin Hospital for the operation in 2016. Court documents say Makenzie contends that the surgery helped alleviate his gender dysphoria.

In his decision, Judge Conley cites guidelines issued by the World Professional Association of Transgender Health to treat transsexual, transgender and gender nonconforming people. Treatments include psychotherapy, hormone therapy and “a number of surgical procedures” to eliminate the development of unwanted secondary sex characteristics of the assigned sex, develop secondary sex characteristics of the sex associated with the patient’s gender identity and enhance the patient’s ability to “pass” as the sex associated with the patient’s gender identity to decrease harassment, mistreatment and other forms of discrimination.