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1.7 million trans people in the U.S. face hardships increasing their risk of poor health. Trans people are more likely to experience harassment, physical, verbal, and sexual assault. All of these issues are amplified for trans POC.

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This post is updated since its original publication on November 8, 2018.

This week the Supreme Court ruled that LGBT people are protected from employment discrimination. This decision comes just a week after the Trump administration finalized a rewrite of Section 1557 of the Affordable Care Act. Section 1557, which prohibits discrimination based on race, color, national origin, sex, age, or disability, was defined in 2016 as applying to gender identity. As a result of that 2016 definition, health providers and insurance companies that received federal funding had to provide the same access to coverage, services, and care to transgender people that they would to cisgender people (i.e., those whose gender identify matches the sex they were assigned at birth).

The new rule effectively eliminates these protections. As a result, trans people may now face discrimination in accessing health services, receiving care consistent with their gender identity, and getting coverage for gender transition services. In the final rule, the U.S. Department of Health and Human Service Office of Civil Rights states that it expects half of 137,501 covered entities - including hospitals, insurers, state Medicaid agencies, community health centers, and physician practices - to rescind these protections through changes in policies and procedures.

The new rule comes during the COVID-19 pandemic, a time when increasing access to care for all patients is critical. This could have devastating implications for the health and health care of transgender and gender-nonconforming individuals during the pandemic and in the long term, placing an already vulnerable population at greater risk.

One of the Most At-Risk Populations

The approximately 1.7 million trans people in the United States face significant hardships that increase their risk of poor health outcomes. First, two of five (39%) report having low incomes (i.e., earning less than $30,000 a year per household), which can have negative effects on health. In addition, trans people are more likely than the general population to face discrimination in education and employment, abuse by the police, harassment in public spaces, and physical, verbal, and sexual assault. Nearly all of these issues are worse for trans people of color.

The toxic stress of living as a trans person in America can negatively affect physical and mental well-being. Trans people are more likely than their cisgender counterparts to report poor physical health, experience mental health issues like anxiety and depression, and have substance abuse problems. Forty percent have attempted suicide, compared with 4.6 percent of the general population.

Poor Access to Quality Health Care

Transgender people often face barriers to getting the health care they need. One of five transgender adults is uninsured. Trans people often skip health care because of cost: nearly half (48%) have postponed medical care when sick or injured and avoided preventive care (50%) because they couldn't afford it.

Trans people often hide their gender identities from health providers out of fear of retaliation and harassment. Only 40 percent of trans people report being out to all their medical providers. It's understandable that many would want to conceal this information: 28 percent of trans people report experiencing verbal harassment in a medical setting and 19 percent report having been refused medical care by providers because of their gender identity. Because of stigmatization and harassment, 28 percent of trans people report avoiding care altogether.

Of those who do make it to the doctor and disclose their gender identity, half report having to teach their medical providers about transgender individuals' health care needs and appropriate medical care. Lack of awareness on the part of medical providers - in part because of lack of training - has serious implications for care quality. Moreover, when people veil their identities in medical settings, their providers miss important information that should inform screening, diagnosis, and care.

The Consequences of Erasing Transgender Rights

For trans people, health care visits can add to distress, rather than provide help. The American Medical Association (AMA) opposes policies like the final rule that could harm trans people, stating that "laws and policies that restrict the use of public facilities based on biological gender can have immediate and lingering physical consequences, as well as severe mental health repercussions." The AMA recommends equal access to care that corresponds with a person's gender identity "to protect the public health and to promote social equality and safe access to public facilities and services."

Now that the protections of Section 1557 no longer apply to trans people, they may face greater discrimination, leading to more avoidance of care and, ultimately, more unmet medical and behavioral health needs.

The announcement of the rule comes during the COVID-19 crisis when access to care is critical. In the long term, however, the rule will face legal challenges that will be difficult for the administration to defend. The Supreme Court ruled this week that Title VII of the Civil Rights Act of 1964, which prohibits employment discrimination, also applies to LGBT individuals.

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Federal Government Eliminates Health Care Protections for Transgender Americans

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A move towards defining gender as sex at birth could have devastating implications for the health and health care of transgender and gender nonconforming individuals, placing an already vulnerable population at even greater risk. (This post is updated since its original publication on November 8, 2018.)

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Human Rights CAmpaign plans to sue the Trump administration for exceeding their legal authority. Trump also finalized the rule on the anniversary of the Pulse shooting.Lawsuits will test how this rule holds up in court, including one from Alexander Pangborn, a nurse who was denied health care for his needs.

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The U.S. Department of Health and Human Services Friday announced changes to the Affordable Care Act that reverse protections for transgender people added by President Barack Obama's administration in 2016. The Obama-era rule governing enforcement of Section 1557 of the ACA had defined gender as "one's internal sense of gender, which may be male, female, neither, or a combination of male and female." Today's announcement signaled a return to the original text of the law.

"Today's rule attempts to gut the robust nondiscrimination protections under the Health Care Rights Law, Section 1557 of the Affordable Care Act (ACA)," Winnie Stachelberg, executive vice president for external affairs at the Center for American Progress, said in a written statement. "This move by the administration to undermine anti-discrimination protections in health care for LGBTQ people, women, people with limited English proficiency, people with disabilities, and others, including those who face multiple forms of discrimination, is unconscionable at any time."

Section 1557 of the ACA made it illegal to discriminate due to "race, color, national origin, sex, age or disability in certain health programs and activities." The Obama administration had sought to strengthen those protections with the refined definition, but was met with immediate opposition in the courts, which ultimately agreed with the Trump administration's interpretation of the law. The current administration had issued a proposed rule changing that interpretation in May 2019, and today's move finalizes that rule. When presidential administrations make rules affecting enforcement of laws, the proposed rule goes through a period of public comment before it is finalized, but the rulemaking process does not require congressional action.

The new language also removes antidiscrimination protections for the groups of people Stachelberg noted, and allows for wide-ranging exemptions from providing services related to abortion if health care workers have faith-based objections. The Obama administration's rule also could be used to address discrimination based on sexual orientation if it was rooted in sex stereotyping - for instance, denial of fertility services to a female couple because a provider believes only opposite-sex couples should be parents.

"HHS respects the dignity of every human being, and as we have shown in our response to the pandemic, we vigorously protect and enforce the civil rights of all to the fullest extent permitted by our laws as passed by Congress," Roger Severino, director of the Office for Civil Rights at HHS, said in a statement announcing the decision. "We are unwavering in our commitment to enforcing civil rights in healthcare." Severino, by the way, has a long history of bigotry against LGBTQ+ people, along with a record of opposition to women's rights.

Experts were quick to express concern, though.

Lynn Dawson, associate director of HIV policy at the Kaiser Family Foundation, told NPR that changes will be felt beyond basic health care issues. She says insurance companies might be able to raise premium prices for LGBTQ+ people, and trans patients might find limited remedies through the legal system.

"Because of limited access to litigation, I think that it's fair to state that the ramifications [of this rule] could be pretty significant," she lamented.

Several LGBTQ+ groups, other civil rights groups, and medical organizations issued statements condemning the administration's action, and the Human Rights Campaign plans to sue over it.

"We cannot and will not allow Donald Trump to continue attacking us. Today, the Human Rights Campaign is announcing plans to sue the Trump administration for exceeding their legal authority and attempting to remove basic health care protections from vulnerable communities including LGBTQ people. And, to add insult to injury, the administration finalized this rule on the anniversary of the Pulse shooting, where a gunman killed 49 people in an LGBTQ nightclub," said HRC President Alphonso David. "LGBTQ people get sick. LGBTQ people need health care. LGBTQ people should not live in fear that they cannot get the care they need simply because of who they are. It is clear that this administration does not believe that LGBTQ people, or other marginalized communities, deserve equality under the law. But we have a reality check for them: we will not let this attack on our basic right to be free from discrimination in health care go unchallenged. We will see them in court, and continue to challenge all of our elected officials to rise up against this blatant attempt to erode critical protections people need and sanction discrimination."

A lawsuit already filed will test the rule, according to GLBTQ Legal Advocates and Defenders. Its suit, Pangborn v. Ascend, was filed in January in federal court in Massachusetts. GLAD is representing Alexander Pangborn, a transgender man who was denied gender-affirming care under his employer's health insurance plan.

"Alexander Pangborn is a hospice nurse who provides compassionate care every day to his patients and their families, yet he was denied access to the health care he himself needs," said Chris Erchull, the GLAD staff attorney representing Pangborn, in a press release. "The purpose of the ACA is to ensure Americans have access to healthcare. The purpose and the legal meaning of the nondiscrimination protections in Section 1557 are to ensure that individuals like Alexander are not denied care because of anti-transgender prejudice or other bias. The Trump administration's repudiation of those protections is both cruel and unjust. It will not hold up in court."

Numerous other organizations weighed in.

"Trans people should be able to seek medical care when we need help without being turned away or denied treatment because of who we are," said Kris Hayashi, executive director of the Transgender Law Center. "This appalling move by the Trump administration puts the lives of trans people in jeopardy - especially trans people living with HIV, Black trans people and trans people of color, trans people with disabilities, and trans people living in rural areas and in Southern states."

"Even as the death toll and catastrophe of the COVID-19 pandemic grows and people take to the streets, the Trump administration remains focused on denying equal access to health care to transgender people," said Mara Keisling, executive director of the National Center for Transgender Equality. "The Trump administration has waged a nonstop campaign against transgender people, taking every opportunity to deny us the ability to live our lives as who we are. The new rules released today are hateful and cruel, and will keep people from being able to get the care they need to live happy, healthy, and productive lives."

"It is particularly brazen of Secretary of Health and Human Services Alex Azar and the President to undermine health care access at a time when the nation is confronted by the coronavirus," said Andy Marra, Executive Director of the Transgender Legal Defense & Education Fund. "Today's published rule demonstrates this administration would rather promote discrimination in health care than deliver a comprehensive and evidence-based response to the pandemic. We look forward to challenging these reckless regulations alongside our partners to ensure trans protections remain intact."

"Respect for the diversity of patients is a fundamental value of the medical profession and is reflected in long-standing AMA policy opposing discrimination based on race, gender, sexual orientation, gender identity or a woman's decisions about pregnancy, including termination," said Susan R. Bailey, president of the American Medical Association. "The federal government should never make it more difficult for individuals to access health care - during a pandemic or any other time."

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Trump Administration Kills Trans Protections in Affordable Care Act

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The U.S. Department of Health and Human Services Friday announced changes to the Affordable Care Act that reverse protections for transgender people added by President Barack Obama's administration in 2016. The Obama-era rule governing enforcement of Section 1557 of the ACA had defined gender as "one's internal sense of gender, which may be male, female, neither, or a combination of male and female."

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However, people mistakenly may think it's okay to discriminate against trans people in healthcare or housing. This can lead to more discrimination. For the housing rule, discrimination extends to simply identifying trans people on their appearance, even if they're not trans.

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The Trump administration is pressing forward with policies limiting transgender rights. Many rules that have been in development for years have now either been finalized or have gone into effect.

The Trump administration policy is a small piece of a broader, government-wide effort to diminish protections for transgender people. Credit... Doug Mills/The New York Times

WASHINGTON - The Trump administration on Friday published its rule allowing single-sex homeless shelters to exclude transgender people from facilities that correspond with their gender identity, pressing forward with limits on transgender rights despite a Supreme Court ruling that extended civil rights protection to transgender people.

The new rule on homeless shelters will go into effect after a 60-day comment period. Administration officials argue that it will make women's shelters safer by preventing men from gaining access to abuse or attack women seeking protection.

Transgender rights groups say it is more likely to force some transgender women to go to men's shelters where they could face assault.

The policy is just a small piece of a broader, governmentwide effort to diminish protections for transgender people. President Trump's 2017 ban on transgender people enlisting or serving in the military has now been in effect for more than a year. A Department of Health and Human Services rule erasing protections for transgender patients against discrimination by doctors, hospitals and health insurance companies was finalized in June.

The Education Department has rescinded Obama-era rules that allowed transgender students to use bathrooms of their choice or participate in sports corresponding with their gender identity. The Justice Department has moved to roll back protections for transgender people in federal prisons, and the Office of Personnel Management has suspended protections for transgender employees of federal contractors.

"Across the board, when you're cut out of the federal protections you used to have, people are more likely to experience discrimination, and they're less likely to talk about it," said Robin Maril, an associate legal director at the Human Rights Campaign, the largest L.G.B.T. rights group.

"It has a significant chilling effect," she added.

The Department of Housing and Urban Development did not respond to questions about the new shelter rule, but Ben Carson, the secretary of housing and urban development, has previously expressed concern about "big, hairy men" entering women's shelters.

"The current HUD rule permits any man, simply by asserting that his gender is female, to obtain access to women's shelters and even precludes the shelter from asking for identification," Mr. Carson said last week in a letter to Democratic lawmakers in the House obtained by The New York Times.

Transgender rights groups say transgender women are the ones at risk. In a report released in 2011 by the National Center for Transgender Equality and the National Gay and Lesbian Task Force, more than half of the transgender people who had used a homeless shelter said they had been harassed.

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Protesters rallying to call attention to violence against Black transgender people in Brooklyn last month. Credit... Demetrius Freeman for The New York Times

The rule, first announced three weeks ago, was published in the Federal Register a month after the Supreme Court ruled that transgender people cannot be fired or otherwise discriminated against in the work force, because federal protections against sex discrimination apply to gay, bisexual and transgender people. The ruling in the case, Bostock v. Clayton County, Ga., was a landmark moment for gay and transgender rights.

"Secretary Carson's insistence on pressing forward with this discriminatory policy - despite the Bostock ruling and clear consensus among experts and service providers opposed to this rule change - betrays a disturbing determination to target and endanger trans Americans," Representative Jennifer Wexton, Democrat of Virginia, said in a statement.

Transgender rights groups and others are likely to sue to try to block the homeless shelter rule, as they have on other administration regulations on transgender rights. A coalition of 23 Democratic attorneys general filed a lawsuit on Monday seeking to block the Health and Human Services rule on transgender health care under the Affordable Care Act from going into effect next month.

Roger Severino, the director of the office for civil rights at the Department of Health and Human Services, which was responsible for the rule, said the health law's anti-discrimination provision had been "held unlawful and unenforceable by a federal court in December 2016."

"We at H.H.S. respect the dignity of every human being and are committed to vigorously enforcing civil rights protections in health care, especially during the pandemic," he added.

Democratic attorneys general interpreted it differently.

"By rolling back rules that ensure the A.C.A. protects all Americans, the president is unlawfully giving health care providers and insurers license to deny care to LGBTQ+ individuals," New York State Attorney General Letitia James said in a statement. "It is never acceptable to deny health care to Americans who need it, but it is especially egregious to do so in the middle of a pandemic."

The American Civil Liberties Union filed a lawsuit on behalf of Jesse Hammons, a transgender man, against the University of Maryland Medical System last week, saying that he was denied gender surgery "because the surgery conflicted with the hospital's Catholic religious beliefs."

Gabriel Arkles, a senior staff attorney at the A.C.L.U., said he is convinced the Affordable Care Act still protects transgender patients, regardless of what the administration says, but the new policy could discourage transgender people from seeking health care.

"Even if people are mistakenly thinking that now it's OK to discriminate against trans people in health care or housing, that can lead to more instances of discrimination," Mr. Arkles said.

Transgender rights groups say that such discrimination will extend to people who are not transgender. The housing department's rule change for homeless shelters has language detailing methods of identifying transgender people based on their appearance.

"Reasonable considerations may include, but are not limited to, a combination of factors such as height, the presence (but not the absence) of facial hair, the presence of an Adam's apple, and other physical characteristics which, when considered together, are indicative of a person's biological sex," the text reads.

Promoters of transgender rights say the new rule could even deny shelter to people who are mistaken as transgender. For example, a medical condition that causes excess facial and body hair growth affects around 5 percent to 10 percent of women, according to the Indian Journal of Dermatology, and is more common in women of color.

"The idea that you can create some kind of gender surveillance checklist that some front desk staff person is forced to look through as clients come in the door, it's deeply disturbing," said Dylan Waguespack, the director of public policy at True Colors United, which works on preventing homelessness among L.G.B.T. youth. "It's Orwellian."

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Trump Presses Limits on Transgender Rights Over Supreme Court Ruling

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The Trump administration is pressing forward with policies limiting transgender rights. Many rules that have been in development for years have now either been finalized or have gone into effect.

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Congress could invalidate it if within 60 days that Congress is in session, Trump were no longer president and simple majorities in Congress in both chambers voted to block the rule. The date for the final rule to avoid this is uncertain. LGBTQ activist group Lambda Legal said it would challenge this new rule in court. Lawsuits resulting in a judge putting the rule on hold could stop the rule, but if not, it is set to go into effect 60 days from the date that the rule is published in the Federal Register.

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Updated at 7:29 p.m. ET
The Trump administration on Friday finalized a rule that would remove nondiscrimination protections for LGBTQ people when it comes to health care and health insurance.

"HHS respects the dignity of every human being, and as we have shown in our response to the pandemic, we vigorously protect and enforce the civil rights of all to the fullest extent permitted by our laws as passed by Congress," said Roger Severino, who directs the Office for Civil Rights in the Department of Health and Human Services, in a written statement announcing that the HHS rule had become final. The rule is set to go into effect by mid-August.

It is one of many rules and regulations put forward by the Trump administration that defines "sex discrimination" as only applying when someone faces discrimination for being female or male, and does not protect people from discrimination on the basis of sexual orientation or gender identity.

Supporters of the new rule said this is a necessary reversal of Obama-era executive overreach and will reduce confusion about the legal meaning of "sex discrimination." Critics argue the rule could further harm an already vulnerable group - transgender people - in the midst of a pandemic and historic unrest spurred by the killing of George Floyd at the hands of police in Minneapolis.

"I can't help but wonder if the timing [of this rule] is by design so that this is something that people won't pay attention to," said Tia Sherèe Gaynor, a political science professor at the University of Cincinnati.
What the final rule does
The rule focuses on nondiscrimination protections laid out in Section 1557 of the Affordable Care Act. That federal law established that it is illegal to discriminate on the basis of "race, color, national origin, sex, age or disability in certain health programs and activities." In 2016, an Obama-era rule explained that protections regarding "sex" encompass those based on gender identity, which it defined as "male, female, neither, or a combination of male and female."

In June 2019, under Trump, the HHS Office for Civil Rights proposed a rule (the one finalized this week) that reverses the one from the Obama administration.

Severino said at the time, "We're going back to the plain meaning of those terms, which is based on biological sex." He also said the rule could save hospitals and insurers and others $2.9 billion over five years since they will be relieved of the requirement to print notices of nondiscrimination in several languages and include them with any "significant" mailings.

Under the new rule, a transgender person could, for example, be refused care for a checkup at a doctor's office, said Lindsey Dawson, associate director of HIV policy at the Kaiser Family Foundation. Other possible scenarios include a transgender man being denied treatment for ovarian cancer, or a hysterectomy not being covered by an insurer - or costing more when the procedure is related to someone's gender transition.

The Trump rule makes changes to gender-based discrimination protections beyond Section 1557 of the ACA; it affects regulations pertaining to access to health insurance, for example, including cost-sharing, health plan marketing and benefits. The rule could also mean that those seeking an abortion could be denied care if performing the procedure violates the provider's moral or religious beliefs.

Even with the rule now finalized, an LGBTQ person who is discriminated against or denied health care can still sue, and courts may rule that their civil rights were violated in such a case. But that's not an easy avenue, Dawson said.

"Because of limited access to litigation, I think that it's fair to state that the ramifications [of this rule] could be pretty significant," she said. Protections will also vary based on where someone lives, she added, so the rule "creates a patchwork of civil rights, compared to standardized protections."

For Severino, this move has been a long time coming. He joined the Trump administration from the Heritage Foundation, a conservative think tank, where he wrote a paper on gender protections in Section 1557. He's also a devout Catholic and, as director of the Office for Civil Rights, has made protections of religious freedom a key focus, including the right of doctors to refuse to provide care that contradicts their religious or moral beliefs.

The rule the HHS proposed on gender and discrimination in health care garnered 155,966 public comments. The final rule is nearly identical to the original version proposed last year.

Conservative groups, including the Christian Medical Association, the Susan B. Anthony List and the Heritage Foundation, applauded the new HHS guidance.

"Health professionals know they must base medical decisions on biology and science, not ideology," Dr. Jeff Barrows, the Christian Medical Association's executive vice president for bioethics and public policy, said after hearing the announcement.

"We are hopeful that this rule will help steer consideration of gender issues in health care back toward science and away from politics and ideology, back to the protection of professional medical judgment and the freedom to adhere to long-observed ethical and moral standards."

Ryan Anderson, a senior research fellow at the Heritage Foundation and former colleague of Severino's, submitted a comment in support of the rule. Anderson said it simply reverses what he sees as the Obama administration's executive overreach.

"Just for the lawmaking process, it's important that the Trump administration clarify that that's not what Congress had in mind when they used the word 'sex,' " he said.
Critics worry about access to health care, especially in a pandemic
Mari Brighe, a freelance writer and transgender woman who lives outside Detroit, called the rule "terrifying."

"I can relate a decade of stories about getting terrible health care because I'm trans," Brighe said. "We walk into any given health care situation not knowing whether doctors are going to treat us well, whether we're going to get high quality care, whether any given, random health care person is going to be terrible to us."

Once, when seriously ill with the flu and having trouble breathing, Brighe recalled, she was sent home from a hospital in rural New York and ended up driving 90 minutes and crossing a lake by ferry to get treatment at a hospital in Vermont.

She said worries now that the rule could make transgender people - who are already reluctant to seek medical care - all the more likely to avoid coronavirus treatment and testing.

"The way that [the rule] reads to me is that people could refuse to collect your COVID specimen because they don't want to touch a trans person," she said. "That's a recipe for spreading a really terrible pandemic among a really, really vulnerable population."

"I can't help but think about how this impacts black trans people," said Gaynor, the political science professor, who noted that African American transgender people are "arguably the most marginalized group in our country."

African Americans who get COVID-19 are much more likely to die from that disease than are white Americans, statistics show. A recent report from the Williams Institute at UCLA estimates that hundreds of thousands of transgender adults may be especially vulnerable to COVID-19 because they have an underlying condition, are over 65, lack health insurance or live in poverty.

For black transgender people, Gaynor said, "it's layers of oppression - it's transphobia on top of racism on top of economic oppression." All of that could affect their ability to get health care during the pandemic, she said, which in turn could have public health implications for all.

Katie Keith, a health law professor at Georgetown University, noted that the new rule could have another chilling effect. "Even if no one actually does discriminate more because of the rule, you've created a fear," Keith said.

She pointed to research documenting how the "public charge" rule - which penalizes people who are seeking to become citizens if they use public safety net programs such as nutrition and housing assistance - affected people and programs outside the scope of the rule itself.

"When they target these vulnerable populations, you see less enrollment in health insurance," she said. "You see folks scared to go to the doctor."

Although the Heritage Foundation's Anderson supports the rule, he said the prospect that it could have a chilling effect is "a very reasonable concern."

"I don't think any reasonable person wants to see transgender people not enrolling in health care plans and not having access to health care," Anderson said. What's needed, he said, is a "finer grain" approach to this issue - such as a new law in Congress that protects LGTBQ people from health care discrimination generally but carves out protection for providers to refuse to provide care related to sex reassignment.
What's next? a word from the high court and, perhaps, Congress
Now that it's marked "final," this rule - which was issued by an agency of the executive branch - may now encounter hurdles via the two other branches of the federal government.

This month, for example, the U.S. Supreme Court is set to weigh in on two major cases on the meaning of the word "sex" in employment discrimination. The two cases involve issues closely related to the legal questions at play in Severino's HHS rule, and the high court's decision might have major implications for the rule's legal footing.

"It's wild that they're finalizing this rule before we have the Supreme Court decision," Keith said.

Meanwhile, in Congress, House Democrats have already asserted that they strongly disagree with the HHS rule. In early May, Speaker Nancy Pelosi issued a statement that read, in part: "The Administration must immediately abandon this outrageous, un-American plan and give LGBTQ individuals the reassurance that they will never be denied the health care they or their families need."

Now that the final rule is out, Congress does have a way of invalidating it, using the Congressional Review Act. That would only happen in this case if - within 60 days that Congress is in session - Trump were no longer president, and simple majorities in both chambers of Congress voted to block the rule. Even if Democrats win big in November, it's not clear if that's a possibility given the tricky timeline - Congress is typically in recess in August, and the COVID-19 pandemic may complicate matters further

The date at which the final rule would be able to avoid this congressional threat is a moving target, Keith said. "Folks are watching the calendar now [wondering], 'When is that 60-day legislative deadline?' "

What's much more certain, she said, is that there will be lawsuits to try to overturn the rule or block it from going into effect.

On Friday, less than an hour after HHS issued its press release, LGBTQ activist group Lambda Legal said it would challenge the new rule in court.

"Today's rule is a tragically failed public health policy and just flat-out illegal," Omar Gonzalez-Pagan, Lambda Legal senior attorney and health care strategist, said in a written statement. "We will be challenging the rule because at a time when the entire world is battling a dangerous pandemic, which in the United States has infected more than 2,000,000 people and killed more than 116,000, it is critical for everyone to have ready access to the potentially lifesaving health care they need."

Unless someone does file a lawsuit that results in a judge putting the rule on hold, it is set to go into effect 60 days from the date the rule is published in the Federal Register.

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Transgender Health Protections Reversed By Trump Administration

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Updated at 7:29 p.m. ET The Trump administration on Friday finalized a rule that would remove nondiscrimination protections for LGBTQ people when it comes to health care and health insurance.

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Especially during the COVID pandemic, the rule could make transgender people more likely to avoid treatment and testing. Even if no one discriminates more because of the rule, there's a new fear created.

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Updated at 7:29 p.m. ET
The Trump administration on Friday finalized a rule that would remove nondiscrimination protections for LGBTQ people when it comes to health care and health insurance.

"HHS respects the dignity of every human being, and as we have shown in our response to the pandemic, we vigorously protect and enforce the civil rights of all to the fullest extent permitted by our laws as passed by Congress," said Roger Severino, who directs the Office for Civil Rights in the Department of Health and Human Services, in a written statement announcing that the HHS rule had become final. The rule is set to go into effect by mid-August.

It is one of many rules and regulations put forward by the Trump administration that defines "sex discrimination" as only applying when someone faces discrimination for being female or male, and does not protect people from discrimination on the basis of sexual orientation or gender identity.

Supporters of the new rule said this is a necessary reversal of Obama-era executive overreach and will reduce confusion about the legal meaning of "sex discrimination." Critics argue the rule could further harm an already vulnerable group - transgender people - in the midst of a pandemic and historic unrest spurred by the killing of George Floyd at the hands of police in Minneapolis.

"I can't help but wonder if the timing [of this rule] is by design so that this is something that people won't pay attention to," said Tia Sherèe Gaynor, a political science professor at the University of Cincinnati.
What the final rule does
The rule focuses on nondiscrimination protections laid out in Section 1557 of the Affordable Care Act. That federal law established that it is illegal to discriminate on the basis of "race, color, national origin, sex, age or disability in certain health programs and activities." In 2016, an Obama-era rule explained that protections regarding "sex" encompass those based on gender identity, which it defined as "male, female, neither, or a combination of male and female."

In June 2019, under Trump, the HHS Office for Civil Rights proposed a rule (the one finalized this week) that reverses the one from the Obama administration.

Severino said at the time, "We're going back to the plain meaning of those terms, which is based on biological sex." He also said the rule could save hospitals and insurers and others $2.9 billion over five years since they will be relieved of the requirement to print notices of nondiscrimination in several languages and include them with any "significant" mailings.

Under the new rule, a transgender person could, for example, be refused care for a checkup at a doctor's office, said Lindsey Dawson, associate director of HIV policy at the Kaiser Family Foundation. Other possible scenarios include a transgender man being denied treatment for ovarian cancer, or a hysterectomy not being covered by an insurer - or costing more when the procedure is related to someone's gender transition.

The Trump rule makes changes to gender-based discrimination protections beyond Section 1557 of the ACA; it affects regulations pertaining to access to health insurance, for example, including cost-sharing, health plan marketing and benefits. The rule could also mean that those seeking an abortion could be denied care if performing the procedure violates the provider's moral or religious beliefs.

Even with the rule now finalized, an LGBTQ person who is discriminated against or denied health care can still sue, and courts may rule that their civil rights were violated in such a case. But that's not an easy avenue, Dawson said.

"Because of limited access to litigation, I think that it's fair to state that the ramifications [of this rule] could be pretty significant," she said. Protections will also vary based on where someone lives, she added, so the rule "creates a patchwork of civil rights, compared to standardized protections."

For Severino, this move has been a long time coming. He joined the Trump administration from the Heritage Foundation, a conservative think tank, where he wrote a paper on gender protections in Section 1557. He's also a devout Catholic and, as director of the Office for Civil Rights, has made protections of religious freedom a key focus, including the right of doctors to refuse to provide care that contradicts their religious or moral beliefs.

The rule the HHS proposed on gender and discrimination in health care garnered 155,966 public comments. The final rule is nearly identical to the original version proposed last year.

Conservative groups, including the Christian Medical Association, the Susan B. Anthony List and the Heritage Foundation, applauded the new HHS guidance.

"Health professionals know they must base medical decisions on biology and science, not ideology," Dr. Jeff Barrows, the Christian Medical Association's executive vice president for bioethics and public policy, said after hearing the announcement.

"We are hopeful that this rule will help steer consideration of gender issues in health care back toward science and away from politics and ideology, back to the protection of professional medical judgment and the freedom to adhere to long-observed ethical and moral standards."

Ryan Anderson, a senior research fellow at the Heritage Foundation and former colleague of Severino's, submitted a comment in support of the rule. Anderson said it simply reverses what he sees as the Obama administration's executive overreach.

"Just for the lawmaking process, it's important that the Trump administration clarify that that's not what Congress had in mind when they used the word 'sex,' " he said.
Critics worry about access to health care, especially in a pandemic
Mari Brighe, a freelance writer and transgender woman who lives outside Detroit, called the rule "terrifying."

"I can relate a decade of stories about getting terrible health care because I'm trans," Brighe said. "We walk into any given health care situation not knowing whether doctors are going to treat us well, whether we're going to get high quality care, whether any given, random health care person is going to be terrible to us."

Once, when seriously ill with the flu and having trouble breathing, Brighe recalled, she was sent home from a hospital in rural New York and ended up driving 90 minutes and crossing a lake by ferry to get treatment at a hospital in Vermont.

She said worries now that the rule could make transgender people - who are already reluctant to seek medical care - all the more likely to avoid coronavirus treatment and testing.

"The way that [the rule] reads to me is that people could refuse to collect your COVID specimen because they don't want to touch a trans person," she said. "That's a recipe for spreading a really terrible pandemic among a really, really vulnerable population."

"I can't help but think about how this impacts black trans people," said Gaynor, the political science professor, who noted that African American transgender people are "arguably the most marginalized group in our country."

African Americans who get COVID-19 are much more likely to die from that disease than are white Americans, statistics show. A recent report from the Williams Institute at UCLA estimates that hundreds of thousands of transgender adults may be especially vulnerable to COVID-19 because they have an underlying condition, are over 65, lack health insurance or live in poverty.

For black transgender people, Gaynor said, "it's layers of oppression - it's transphobia on top of racism on top of economic oppression." All of that could affect their ability to get health care during the pandemic, she said, which in turn could have public health implications for all.

Katie Keith, a health law professor at Georgetown University, noted that the new rule could have another chilling effect. "Even if no one actually does discriminate more because of the rule, you've created a fear," Keith said.

She pointed to research documenting how the "public charge" rule - which penalizes people who are seeking to become citizens if they use public safety net programs such as nutrition and housing assistance - affected people and programs outside the scope of the rule itself.

"When they target these vulnerable populations, you see less enrollment in health insurance," she said. "You see folks scared to go to the doctor."

Although the Heritage Foundation's Anderson supports the rule, he said the prospect that it could have a chilling effect is "a very reasonable concern."

"I don't think any reasonable person wants to see transgender people not enrolling in health care plans and not having access to health care," Anderson said. What's needed, he said, is a "finer grain" approach to this issue - such as a new law in Congress that protects LGTBQ people from health care discrimination generally but carves out protection for providers to refuse to provide care related to sex reassignment.
What's next? a word from the high court and, perhaps, Congress
Now that it's marked "final," this rule - which was issued by an agency of the executive branch - may now encounter hurdles via the two other branches of the federal government.

This month, for example, the U.S. Supreme Court is set to weigh in on two major cases on the meaning of the word "sex" in employment discrimination. The two cases involve issues closely related to the legal questions at play in Severino's HHS rule, and the high court's decision might have major implications for the rule's legal footing.

"It's wild that they're finalizing this rule before we have the Supreme Court decision," Keith said.

Meanwhile, in Congress, House Democrats have already asserted that they strongly disagree with the HHS rule. In early May, Speaker Nancy Pelosi issued a statement that read, in part: "The Administration must immediately abandon this outrageous, un-American plan and give LGBTQ individuals the reassurance that they will never be denied the health care they or their families need."

Now that the final rule is out, Congress does have a way of invalidating it, using the Congressional Review Act. That would only happen in this case if - within 60 days that Congress is in session - Trump were no longer president, and simple majorities in both chambers of Congress voted to block the rule. Even if Democrats win big in November, it's not clear if that's a possibility given the tricky timeline - Congress is typically in recess in August, and the COVID-19 pandemic may complicate matters further

The date at which the final rule would be able to avoid this congressional threat is a moving target, Keith said. "Folks are watching the calendar now [wondering], 'When is that 60-day legislative deadline?' "

What's much more certain, she said, is that there will be lawsuits to try to overturn the rule or block it from going into effect.

On Friday, less than an hour after HHS issued its press release, LGBTQ activist group Lambda Legal said it would challenge the new rule in court.

"Today's rule is a tragically failed public health policy and just flat-out illegal," Omar Gonzalez-Pagan, Lambda Legal senior attorney and health care strategist, said in a written statement. "We will be challenging the rule because at a time when the entire world is battling a dangerous pandemic, which in the United States has infected more than 2,000,000 people and killed more than 116,000, it is critical for everyone to have ready access to the potentially lifesaving health care they need."

Unless someone does file a lawsuit that results in a judge putting the rule on hold, it is set to go into effect 60 days from the date the rule is published in the Federal Register.

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Transgender Health Protections Reversed By Trump Administration

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Updated at 7:29 p.m. ET The Trump administration on Friday finalized a rule that would remove nondiscrimination protections for LGBTQ people when it comes to health care and health insurance.

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"The HCR Law is Section 1557 of the Affordable Care Act (the ACA, or Obamacare), which prohibits discrimination in health coverage and care. It bans discrimination on the basis of race, color, national origin, sex, age, and disability in health programs and activities that receive federal funding." Trump's rule cuts interpretation of law's proection and removes all prohibition of anti-transgender or anti-LGBTQ bias.
The HCR Law in Section 1557 of the Affordable Care Act is still the law, and most courts say it protects trans people.

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National Center for Transgender Equality

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The Trump Administration has announced that it is planning to roll back an important regulation about the Health Care Rights Law, which protects transgender people from discrimination in health care and insurance coverage. Many people are concerned about what this change to the HCR Law means for them or for their transgender loved ones. The most important thing to remember is that even if the Trump Administration rolls back the regulation, health care discrimination against transgender people will still be illegal, although it might be harder in some ways to enforce your rights.
What is the Health Care Rights Law?
The HCR Law is Section 1557 is the part of the Affordable Care Act (the ACA, or Obamacare) that prohibits discrimination in health coverage and care. It bans discrimination on the basis of race, color, national origin, sex, age, and disability in health programs and activities that receive federal funding. This includes most health facilities, like hospitals or doctors' offices, and most health insurance companies.
What is the regulation that the Trump Administration plans to roll back?
Federal agencies often adopt regulations to explain what different laws mean. In 2016, the Department of Health and Human Services (HHS) adopted a rule explaining what the Health Care Rights Law means and how it plans to enforce it. Regulations like this one don't create new protections that weren't already there or change the law, but they do provide important clarifications about what the law requires.

One of the key things this 2016 regulation clarified is, when the HCR Law prohibits sex discrimination in health care, this includes anti-transgender discrimination. The regulation also clarified important parts of the law related to discrimination based on race, national origin, disability, and more. For more information, read NCTE's FAQ about this regulation.

This regulation made it easier for transgender people to enforce their rights under the HCR Law and get access to the health care they need. But it is important to remember that even if HHS hadn't adopted this regulation, anti-transgender discrimination in health care would have still been illegal under the HCR Law. Numerous courts over nearly two decades have said that federal sex discrimination laws prohibit discrimination against transgender people. HHS simply recognized the existing state of the law and formally clarified that in a regulation.
What happened to the lawsuit challenging the regulation?
After the regulation was adopted, several state officials and organizations sued HHS, saying that the regulation needed to be overturned. They hand-picked a judge in Texas who was known for ruling against the Obama Administration and asked him to temporarily block HHS from enforcing parts of the regulation while the case went forward. As they hoped, this judge ignored t he vast majority of other courts and, in December 2016, ordered HHS to temporarily stop enforcing parts of the regulation, including the parts protecting transgender people. In a highly unusual move, theTrump Administration refused to appeal the judge's ruling. Now, the Trump Administration is saying it plans to roll back or rewrite the regulation, and as a result, the judge has put the case on hold.
What will happen with the regulation now?
We don't know yet what will ultimately happen to the regulation. Formal regulations like the one about HCR Law are different than guidance documents (like the guidance supporting transgender students) or executive orders: it's much harder to roll them back. It can take months or even years to rewrite or undo a regulation, and the Trump Administration would need to first put out a draft regulation and give members of the public enough time to comment on it. We will keep fighting to make sure that the regulation stays in place and we hope you'll join us.

But we do know that for the foreseeable future, HHS will not take any action to help people who have faced anti-transgender discrimination. There are two main ways that the protections under the HCR Law can be enforced: people who experience discrimination can sue in court or they can submit a complaint to HHS and ask it to investigate. HHS will not investigate complaints of anti-transgender discrimination for the time being, but transgender people can still file lawsuits themselves and those lawsuits will continue moving forward in the courts.
Am I still protected from health care discrimination?
Yes. No matter what the Trump Administration does, the Health Care Rights Law is the law of the land, and most courts have said it protects transgender people. Only Congress has the power to change the law by repealing the ACA. However, the Trump Administration's actions will likely cause confusion for many patients, providers, and insurance companies, and it could lead to more anti-transgender discrimination.
What should I do if I face discrimination in health care?
If you have faced discrimination by a health care provider, insurance company, or another health program, reach out to an LGBT-friendly legal organization to get help exploring your options. While NCTE does not take clients or provide direct legal services, you can find contact information for organizations that do here.

Also, remember that many states have their own laws and regulations that protect transgender people from discrimination in health care and insurance coverage. If you face discrimination, you may be able to file a complaint with your state's human rights agency or somewhere else-see our Know Your Rights resource for more information.

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Trump Administration Plan to Roll Back Health Care Nondiscrimination Regulation: Frequently Asked Questions

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The Trump Administration has announced that it is planning to roll back an important regulation about the Health Care Rights Law, which protects transgender people from discrimination in health care and insurance coverage. Many people are concerned about what this change to the HCR Law means for them or for their transgender loved ones.

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Trump administration finalized a rule to remove nondiscrimination protections for LGBTQ people in health care and health insurance in June. A transgender person could be refused a checkup at a doctor's office.

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Updated at 7:29 p.m. ET
The Trump administration on Friday finalized a rule that would remove nondiscrimination protections for LGBTQ people when it comes to health care and health insurance.

"HHS respects the dignity of every human being, and as we have shown in our response to the pandemic, we vigorously protect and enforce the civil rights of all to the fullest extent permitted by our laws as passed by Congress," said Roger Severino, who directs the Office for Civil Rights in the Department of Health and Human Services, in a written statement announcing that the HHS rule had become final. The rule is set to go into effect by mid-August.

It is one of many rules and regulations put forward by the Trump administration that defines "sex discrimination" as only applying when someone faces discrimination for being female or male, and does not protect people from discrimination on the basis of sexual orientation or gender identity.

Supporters of the new rule said this is a necessary reversal of Obama-era executive overreach and will reduce confusion about the legal meaning of "sex discrimination." Critics argue the rule could further harm an already vulnerable group - transgender people - in the midst of a pandemic and historic unrest spurred by the killing of George Floyd at the hands of police in Minneapolis.

"I can't help but wonder if the timing [of this rule] is by design so that this is something that people won't pay attention to," said Tia Sherèe Gaynor, a political science professor at the University of Cincinnati.
What the final rule does
The rule focuses on nondiscrimination protections laid out in Section 1557 of the Affordable Care Act. That federal law established that it is illegal to discriminate on the basis of "race, color, national origin, sex, age or disability in certain health programs and activities." In 2016, an Obama-era rule explained that protections regarding "sex" encompass those based on gender identity, which it defined as "male, female, neither, or a combination of male and female."

In June 2019, under Trump, the HHS Office for Civil Rights proposed a rule (the one finalized this week) that reverses the one from the Obama administration.

Severino said at the time, "We're going back to the plain meaning of those terms, which is based on biological sex." He also said the rule could save hospitals and insurers and others $2.9 billion over five years since they will be relieved of the requirement to print notices of nondiscrimination in several languages and include them with any "significant" mailings.

Under the new rule, a transgender person could, for example, be refused care for a checkup at a doctor's office, said Lindsey Dawson, associate director of HIV policy at the Kaiser Family Foundation. Other possible scenarios include a transgender man being denied treatment for ovarian cancer, or a hysterectomy not being covered by an insurer - or costing more when the procedure is related to someone's gender transition.

The Trump rule makes changes to gender-based discrimination protections beyond Section 1557 of the ACA; it affects regulations pertaining to access to health insurance, for example, including cost-sharing, health plan marketing and benefits. The rule could also mean that those seeking an abortion could be denied care if performing the procedure violates the provider's moral or religious beliefs.

Even with the rule now finalized, an LGBTQ person who is discriminated against or denied health care can still sue, and courts may rule that their civil rights were violated in such a case. But that's not an easy avenue, Dawson said.

"Because of limited access to litigation, I think that it's fair to state that the ramifications [of this rule] could be pretty significant," she said. Protections will also vary based on where someone lives, she added, so the rule "creates a patchwork of civil rights, compared to standardized protections."

For Severino, this move has been a long time coming. He joined the Trump administration from the Heritage Foundation, a conservative think tank, where he wrote a paper on gender protections in Section 1557. He's also a devout Catholic and, as director of the Office for Civil Rights, has made protections of religious freedom a key focus, including the right of doctors to refuse to provide care that contradicts their religious or moral beliefs.

The rule the HHS proposed on gender and discrimination in health care garnered 155,966 public comments. The final rule is nearly identical to the original version proposed last year.

Conservative groups, including the Christian Medical Association, the Susan B. Anthony List and the Heritage Foundation, applauded the new HHS guidance.

"Health professionals know they must base medical decisions on biology and science, not ideology," Dr. Jeff Barrows, the Christian Medical Association's executive vice president for bioethics and public policy, said after hearing the announcement.

"We are hopeful that this rule will help steer consideration of gender issues in health care back toward science and away from politics and ideology, back to the protection of professional medical judgment and the freedom to adhere to long-observed ethical and moral standards."

Ryan Anderson, a senior research fellow at the Heritage Foundation and former colleague of Severino's, submitted a comment in support of the rule. Anderson said it simply reverses what he sees as the Obama administration's executive overreach.

"Just for the lawmaking process, it's important that the Trump administration clarify that that's not what Congress had in mind when they used the word 'sex,' " he said.
Critics worry about access to health care, especially in a pandemic
Mari Brighe, a freelance writer and transgender woman who lives outside Detroit, called the rule "terrifying."

"I can relate a decade of stories about getting terrible health care because I'm trans," Brighe said. "We walk into any given health care situation not knowing whether doctors are going to treat us well, whether we're going to get high quality care, whether any given, random health care person is going to be terrible to us."

Once, when seriously ill with the flu and having trouble breathing, Brighe recalled, she was sent home from a hospital in rural New York and ended up driving 90 minutes and crossing a lake by ferry to get treatment at a hospital in Vermont.

She said worries now that the rule could make transgender people - who are already reluctant to seek medical care - all the more likely to avoid coronavirus treatment and testing.

"The way that [the rule] reads to me is that people could refuse to collect your COVID specimen because they don't want to touch a trans person," she said. "That's a recipe for spreading a really terrible pandemic among a really, really vulnerable population."

"I can't help but think about how this impacts black trans people," said Gaynor, the political science professor, who noted that African American transgender people are "arguably the most marginalized group in our country."

African Americans who get COVID-19 are much more likely to die from that disease than are white Americans, statistics show. A recent report from the Williams Institute at UCLA estimates that hundreds of thousands of transgender adults may be especially vulnerable to COVID-19 because they have an underlying condition, are over 65, lack health insurance or live in poverty.

For black transgender people, Gaynor said, "it's layers of oppression - it's transphobia on top of racism on top of economic oppression." All of that could affect their ability to get health care during the pandemic, she said, which in turn could have public health implications for all.

Katie Keith, a health law professor at Georgetown University, noted that the new rule could have another chilling effect. "Even if no one actually does discriminate more because of the rule, you've created a fear," Keith said.

She pointed to research documenting how the "public charge" rule - which penalizes people who are seeking to become citizens if they use public safety net programs such as nutrition and housing assistance - affected people and programs outside the scope of the rule itself.

"When they target these vulnerable populations, you see less enrollment in health insurance," she said. "You see folks scared to go to the doctor."

Although the Heritage Foundation's Anderson supports the rule, he said the prospect that it could have a chilling effect is "a very reasonable concern."

"I don't think any reasonable person wants to see transgender people not enrolling in health care plans and not having access to health care," Anderson said. What's needed, he said, is a "finer grain" approach to this issue - such as a new law in Congress that protects LGTBQ people from health care discrimination generally but carves out protection for providers to refuse to provide care related to sex reassignment.
What's next? a word from the high court and, perhaps, Congress
Now that it's marked "final," this rule - which was issued by an agency of the executive branch - may now encounter hurdles via the two other branches of the federal government.

This month, for example, the U.S. Supreme Court is set to weigh in on two major cases on the meaning of the word "sex" in employment discrimination. The two cases involve issues closely related to the legal questions at play in Severino's HHS rule, and the high court's decision might have major implications for the rule's legal footing.

"It's wild that they're finalizing this rule before we have the Supreme Court decision," Keith said.

Meanwhile, in Congress, House Democrats have already asserted that they strongly disagree with the HHS rule. In early May, Speaker Nancy Pelosi issued a statement that read, in part: "The Administration must immediately abandon this outrageous, un-American plan and give LGBTQ individuals the reassurance that they will never be denied the health care they or their families need."

Now that the final rule is out, Congress does have a way of invalidating it, using the Congressional Review Act. That would only happen in this case if - within 60 days that Congress is in session - Trump were no longer president, and simple majorities in both chambers of Congress voted to block the rule. Even if Democrats win big in November, it's not clear if that's a possibility given the tricky timeline - Congress is typically in recess in August, and the COVID-19 pandemic may complicate matters further

The date at which the final rule would be able to avoid this congressional threat is a moving target, Keith said. "Folks are watching the calendar now [wondering], 'When is that 60-day legislative deadline?' "

What's much more certain, she said, is that there will be lawsuits to try to overturn the rule or block it from going into effect.

On Friday, less than an hour after HHS issued its press release, LGBTQ activist group Lambda Legal said it would challenge the new rule in court.

"Today's rule is a tragically failed public health policy and just flat-out illegal," Omar Gonzalez-Pagan, Lambda Legal senior attorney and health care strategist, said in a written statement. "We will be challenging the rule because at a time when the entire world is battling a dangerous pandemic, which in the United States has infected more than 2,000,000 people and killed more than 116,000, it is critical for everyone to have ready access to the potentially lifesaving health care they need."

Unless someone does file a lawsuit that results in a judge putting the rule on hold, it is set to go into effect 60 days from the date the rule is published in the Federal Register.

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Transgender Health Protections Reversed By Trump Administration

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Updated at 7:29 p.m. ET The Trump administration on Friday finalized a rule that would remove nondiscrimination protections for LGBTQ people when it comes to health care and health insurance.

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"The Trump administration on Friday published its rule allowing single-sex homeless shelters to exclude transgender people from facilities that correspond with their gender identity, pressing forward with limits on transgender rights despite a Supreme Court ruling that extended civil rights protection to transgender people."

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The Trump administration is pressing forward with policies limiting transgender rights. Many rules that have been in development for years have now either been finalized or have gone into effect.

The Trump administration policy is a small piece of a broader, government-wide effort to diminish protections for transgender people. Credit... Doug Mills/The New York Times

WASHINGTON - The Trump administration on Friday published its rule allowing single-sex homeless shelters to exclude transgender people from facilities that correspond with their gender identity, pressing forward with limits on transgender rights despite a Supreme Court ruling that extended civil rights protection to transgender people.

The new rule on homeless shelters will go into effect after a 60-day comment period. Administration officials argue that it will make women's shelters safer by preventing men from gaining access to abuse or attack women seeking protection.

Transgender rights groups say it is more likely to force some transgender women to go to men's shelters where they could face assault.

The policy is just a small piece of a broader, governmentwide effort to diminish protections for transgender people. President Trump's 2017 ban on transgender people enlisting or serving in the military has now been in effect for more than a year. A Department of Health and Human Services rule erasing protections for transgender patients against discrimination by doctors, hospitals and health insurance companies was finalized in June.

The Education Department has rescinded Obama-era rules that allowed transgender students to use bathrooms of their choice or participate in sports corresponding with their gender identity. The Justice Department has moved to roll back protections for transgender people in federal prisons, and the Office of Personnel Management has suspended protections for transgender employees of federal contractors.

"Across the board, when you're cut out of the federal protections you used to have, people are more likely to experience discrimination, and they're less likely to talk about it," said Robin Maril, an associate legal director at the Human Rights Campaign, the largest L.G.B.T. rights group.

"It has a significant chilling effect," she added.

The Department of Housing and Urban Development did not respond to questions about the new shelter rule, but Ben Carson, the secretary of housing and urban development, has previously expressed concern about "big, hairy men" entering women's shelters.

"The current HUD rule permits any man, simply by asserting that his gender is female, to obtain access to women's shelters and even precludes the shelter from asking for identification," Mr. Carson said last week in a letter to Democratic lawmakers in the House obtained by The New York Times.

Transgender rights groups say transgender women are the ones at risk. In a report released in 2011 by the National Center for Transgender Equality and the National Gay and Lesbian Task Force, more than half of the transgender people who had used a homeless shelter said they had been harassed.

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Protesters rallying to call attention to violence against Black transgender people in Brooklyn last month. Credit... Demetrius Freeman for The New York Times

The rule, first announced three weeks ago, was published in the Federal Register a month after the Supreme Court ruled that transgender people cannot be fired or otherwise discriminated against in the work force, because federal protections against sex discrimination apply to gay, bisexual and transgender people. The ruling in the case, Bostock v. Clayton County, Ga., was a landmark moment for gay and transgender rights.

"Secretary Carson's insistence on pressing forward with this discriminatory policy - despite the Bostock ruling and clear consensus among experts and service providers opposed to this rule change - betrays a disturbing determination to target and endanger trans Americans," Representative Jennifer Wexton, Democrat of Virginia, said in a statement.

Transgender rights groups and others are likely to sue to try to block the homeless shelter rule, as they have on other administration regulations on transgender rights. A coalition of 23 Democratic attorneys general filed a lawsuit on Monday seeking to block the Health and Human Services rule on transgender health care under the Affordable Care Act from going into effect next month.

Roger Severino, the director of the office for civil rights at the Department of Health and Human Services, which was responsible for the rule, said the health law's anti-discrimination provision had been "held unlawful and unenforceable by a federal court in December 2016."

"We at H.H.S. respect the dignity of every human being and are committed to vigorously enforcing civil rights protections in health care, especially during the pandemic," he added.

Democratic attorneys general interpreted it differently.

"By rolling back rules that ensure the A.C.A. protects all Americans, the president is unlawfully giving health care providers and insurers license to deny care to LGBTQ+ individuals," New York State Attorney General Letitia James said in a statement. "It is never acceptable to deny health care to Americans who need it, but it is especially egregious to do so in the middle of a pandemic."

The American Civil Liberties Union filed a lawsuit on behalf of Jesse Hammons, a transgender man, against the University of Maryland Medical System last week, saying that he was denied gender surgery "because the surgery conflicted with the hospital's Catholic religious beliefs."

Gabriel Arkles, a senior staff attorney at the A.C.L.U., said he is convinced the Affordable Care Act still protects transgender patients, regardless of what the administration says, but the new policy could discourage transgender people from seeking health care.

"Even if people are mistakenly thinking that now it's OK to discriminate against trans people in health care or housing, that can lead to more instances of discrimination," Mr. Arkles said.

Transgender rights groups say that such discrimination will extend to people who are not transgender. The housing department's rule change for homeless shelters has language detailing methods of identifying transgender people based on their appearance.

"Reasonable considerations may include, but are not limited to, a combination of factors such as height, the presence (but not the absence) of facial hair, the presence of an Adam's apple, and other physical characteristics which, when considered together, are indicative of a person's biological sex," the text reads.

Promoters of transgender rights say the new rule could even deny shelter to people who are mistaken as transgender. For example, a medical condition that causes excess facial and body hair growth affects around 5 percent to 10 percent of women, according to the Indian Journal of Dermatology, and is more common in women of color.

"The idea that you can create some kind of gender surveillance checklist that some front desk staff person is forced to look through as clients come in the door, it's deeply disturbing," said Dylan Waguespack, the director of public policy at True Colors United, which works on preventing homelessness among L.G.B.T. youth. "It's Orwellian."

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Trump Presses Limits on Transgender Rights Over Supreme Court Ruling

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The Trump administration is pressing forward with policies limiting transgender rights. Many rules that have been in development for years have now either been finalized or have gone into effect.

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Federal government have been actively trying to block or have blocked trans rights: banned transgender service in the military, Education Department tried to block transgender students from choosing which bathroom to use, Department of Health and Human Services have rolled back on health care protections for trans people, Justice Department moved to end protections for transgender people in federal prison.

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L.G.B.T.Q. advocates say the president has tried to divide their coalition by targeting transgender people in policy rollbacks.

President Trump in Bedminster, N.J., in August. Mr. Trump's advisers are suddenly talking about L.G.B.T.Q. people as they scramble to find new voter support. Credit... Erin Schaff/The New York Times

The month of June was filled with big moments for lesbian, gay, bisexual and transgender people.

In that monthlong stretch, the Supreme Court rendered a sweeping decision providing workplace protections for gay and transgender people. It came shortly before the fifth anniversary of the high court's landmark ruling on marriage equality. L.G.B.T.Q. people and others commemorated the murder of 49 people at the Pulse nightclub in Florida in June 2016. Thousands marched in Brooklyn, N.Y., in support of Black transgender lives.

President Trump was almost entirely silent through it all.

There was no tweet in honor of Pride Month, despite suggestions from several aides to Mr. Trump that he write one. No rollout of a coalition aimed at L.G.B.T.Q. voters by his campaign, despite preparations that had been made for one. Embassies overseas were told they couldn't fly the Pride flag.

There was, however, a rollback by the Trump administration of a regulation put in place by the Obama administration in 2016 to mandate health care as a civil right for transgender patients under the Affordable Care Act.

It is what many in the L.G.B.T.Q. coalition have come to expect from Mr. Trump, who during his 2016 presidential campaign used gay people as a wedge against Muslims, whom he painted broadly as extremists, following the shootings at Orlando's Pulse nightclub by a Muslim man. While Mr. Trump has signaled a willingness to publicly align himself with some gay men and women, he selected a deeply conservative running mate in Vice President Mike Pence, and, as president, has systematically dismantled protections implemented by President Barack Obama, especially for transgender people.

Just over two months before Election Day, Mr. Trump is trailing in almost every poll to Joseph R. Biden Jr., the Democratic nominee, whom activists credit with pushing Mr. Obama to support gay marriage. And Mr. Trump's advisers are suddenly talking about L.G.B.T.Q. people as they scramble to find new voter support.

Last weekend, the campaign announced the L.G.B.T.Q. coalition that had been expected in June, blaming the delay on the coronavirus.

And now Trump officials are turning to Richard Grenell, the openly gay former U.S. ambassador to Germany who served for three months as the acting director of national intelligence, to sell the president, and to attack Mr. Biden.

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Richard Grenell, center, in 2019. Mr. Grenell claimed that Mr. Trump is the "most pro-gay president in American history," in a video by the Log Cabin Republicans. Credit... Odd Anderson/Agence France-Presse - Getty Images

Alphonso David, the president of the Human Rights Campaign, the largest L.G.B.T.Q. civil rights group, responded, "We're not taking the bait."

For years, now, Mr. David said, the president has tried to divide the coalition by targeting transgender people in particular, with actions that affect the entire coalition.

"The Trump administration is looking to drive a wedge within the L.G.B.T.Q. community between L.G.B. and T.," Mr. David said.

Tori Cooper, the group's director of community engagement for the transgender justice initiative, said that the administration in is especially focused on people who have the least protection in society, transgender people of color.

"It shows the cowardice - that's the word I like to use of the current president," Ms. Cooper said.

The targeting of transgender people has extended across the federal government: a ban on transgender service in the military, an effort at the Education Department to block transgender students from choosing which bathroom to use, the rollback of health care protections by the Department of Health and Human Services, the Justice Department's move to end protections for transgender people in federal prisons.

Last month, the Department of Housing and Urban Development proposed allowing homeless shelters to deny transgender people access to single-sex shelters, and this month, the Education Department's office of civil rights publicly moved to block transgender girls from joining female track teams in Connecticut high schools.

Mr. Grenell, in the video, cited almost no specific domestic policy accomplishment that Mr. Trump achieved on L.G.B.T.Q. rights, as he made the pitch that Mr. Trump is the "most pro-gay president in American history." Instead, Mr. Grenell referred to his own appointment, as well as to the president's acceptance of the Supreme Court's ruling of gay marriage as constitutional and his efforts to push countries that criminalize being gay to end those practices. In the video, Mr. Grenell specifically mentioned gays and lesbians, but not transgender people.

And the night before Mr. Grenell's scheduled speech, a convention speaker praised Mr. Trump for his administration's revocation of some protections for transgender students.

To describe Mr. Trump as supportive of gay people because he appointed Mr. Grenell is the essence of "tokenism," Mr. David said.

"It's actually offensive," he said, "because you are appointing someone but removing all the rights associated with that identity."

Some administration officials have acknowledged that they see targeting transgender rights as different from gay rights.

A vigil following the Pulse nightclub shootings. During his 2016 presidential campaign, Mr. Trump used gay people as a wedge against Muslims, whom he painted broadly as extremists, following the shootings at Orlando's Pulse nightclub by a Muslim man. Credit... Ángel Franco/The New York Times

In a statement, Judd Deere, a White House spokesman, said, "While the radical left has pushed false and disgusting accusations that L.G.B.T. Americans, which includes me, are threatened under this administration, that could not be further from the truth."

Mr. Judd said that Mr. Trump has hired L.G.B.T.Q. people across the government, mentioning Mr. Grenell again, cited the president's commitment at last year's State of the Union address to ending H.I.V. transmissions in the country by 2030, and saying the president "launched a global campaign to decriminalize homosexuality, standing in solidarity with all L.G.B.T. people who live in dozens of counties around the globe that punish, imprison and even execute individuals based on their sexual orientation."

There's no evidence that Mr. Trump's campaign to decriminalize homosexuality has had any impact, or that it's been substantially different than what Mr. Obama had attempted. For instance, White House officials declined to say whether Mr. Trump had raised the brutal anti-gay purges by the Chechen leader Ramzan Kadyrov with President Vladimir V. Putin of Russia, with whom he's spoken several times in recent months. His H.I.V. pledge was similarly met with skepticism.

Mr. Trump is famously transactional, and the support he has given L.G.B.T.Q. people has usually been in connection with celebrity or support they have given him.

Mr. Trump allowed gay members into his Florida club Mar-a-Lago as long as they could pay the exorbitant membership fee; he broadcast donations to groups like the Gay Men's Health Crisis when the AIDS epidemic became a celebrity cause; and he publicly embraced the civil union between the singer Elton John, someone whose music and fame Mr. Trump admires, and Mr. John's longtime partner, David Furnish.

In 2015, when Mr. Trump was just a few months into the Republican primary contest, some of his advisers discussed a plan for exiting the campaign if his poll numbers dropped. The plan, according to one person with direct knowledge of the discussions, was for Mr. Trump to say that the party did not agree with him on a number of issues, including gay marriage, even though he'd never publicly supported it.

But after Mr. Trump won the New Hampshire primary, his advisers knew he needed the support of evangelical voters. So in an interview with the former Fox News host Bill O'Reilly in 2016, Mr. Trump said, "I take a lot of heat because I come from New York. You know, from New York, it's like, how you can be against gay marriage? But I'm opposed to gay marriage."

Christine Quinn, the first openly gay speaker of the New York City Council, said Mr. Trump's New York business background makes his actions as president "worse - because he knows better."

As president, Mr. Trump has not demagogued L.G.B.T.Q. issues the way he has with immigrants, Muslims and Black people protesting systemic police brutality.

But Mr. Trump's embrace of initiatives promoting religious freedom has been used by people inside and outside his government to justify discrimination against gay and transgender people.

Christine Quinn during a gathering of the L.G.B.T.Q. community in Manhattan in 2017 protesting Mr. Trump's agenda. Credit... Andrew Kelly/Reuters

Over many years, Mr. Trump has been skeptical about whether he gets any political benefit from the L.G.B.T.Q. community, turning frequently to Mr. Pence, who was Mr. Trump's bridge to evangelical voters in 2016, for advice, according to administration officials. Those are the voters Mr. Trump is most anxious about losing.

Charles Moran, a spokesman for the Log Cabin Republicans, conceded that he would have preferred that Mr. Trump acknowledge Pride Month in June. But he maintained that the president is being treated unfairly and said that Mr. Obama's pro-L.G.B.T.Q. regulations were legal overreach.

"The L.G.B.T. left and what I call 'Gay Inc.' has hijacked the narrative," Mr. Moran said, adding that he himself had to get educated quickly on transgender-related issues. He accused groups like the Human Rights Campaign of being unwilling to engage with the White House.

"My phone calls get returned" by the White House, he said. "There is a genuine willingness to work with us in our community."

The Log Cabin Republicans did not endorse Mr. Trump in 2016, and the group's current support has caused a rift within its ranks. Jerri Ann Henry, the group's first woman executive director, resigned in August 2019 over the pending endorsement.

"Ultimately what should be promised is not devotion to a specific class or group of people but dedication to the set of principles," she said, "and Trump has not shown his devotion to that set of principles."

Last month, Mr. Trump was questioned about whether he would consider rescinding his ban on transgender people entering the military by a reporter for The Washington Blade, a gay newspaper.

Mr. Trump gestured to his chin, appearing to signal the reporter's mask was muffling him.

"I can't hear you," Mr. Trump said. "I can't hear a word you're saying." He never answered the question.

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After Three Years of Attacking L.G.B.T.Q. Rights, Trump Suddenly Tries Outreach

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L.G.B.T.Q. advocates say the president has tried to divide their coalition by targeting transgender people in policy rollbacks. The month of June was filled with big moments for lesbian, gay, bisexual and transgender people. In that monthlong stretch, the Supreme Court rendered a sweeping decision providing workplace protections for gay and transgender people.

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Only 21 states fully prohibit LGBTQ discrimination. "In 27 states, there are no explicit statewide laws at all protecting people from discrimination on the basis of sexual orientation or gender identity in employment, housing and public accommodations." 2 states have some protection, but no explicit protections on gender identity or for public accommodations.

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States with No LGBTQ Non-Discrimination Protections

In 28 states, there are no explicit statewide laws at all protecting people from discrimination on the basis of sexual orientation or gender identity in employment, housing and public accommodations:

States with Non-Discrimination Laws Lacking Gender Identity Protections

In 1 state, state law protects people from discrimination on the basis of sexual orientation in employment, housing and public accommodations - but there are no explicit protections from discrimination on the basis of gender identity.

States with Some LGBTQ Non-Discrimination Protections

While state law in Utah protects people from discrimination on the basis of sexual orientation and gender identity in employment and housing, the state has no public accommodations statues.

States with Full LGBTQ Non-Discrimination Protections

In 20 states and the District of Columbia, state law protects people from discrimination on the basis of sexual orientation and gender identity in employment, housing and public accommodations:

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LGBTQ Americans Aren't Fully Protected From Discrimination in 30 States

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In 28 states, there are no explicit statewide laws at all protecting people from discrimination on the basis of sexual orientation or gender identity in employment, housing and public accommodations: In 1 state, state law protects people from discrimination on the basis of sexual orientation in employment, housing and public accommodations - but there are no explicit protections from discrimination on the basis of gender identity.

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A study from UCLA found that cisgender LGB people were significantly more likely to report experiences of discrimination at work, seeking housing, and being bullied in their childhoods.

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87% of large firms with opposite-sex spousal coverage had coverage for same-sex couples, and 62% of small employers offered coverage to same -sex couples.

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Using the latest data from our annual Employer Health Benefits Survey (EHBS), we assessed access to employer sponsored health insurance (ESI) coverage for same sex spouses in 2018, as well as trends over time; ESI remains the primary way people in the U.S. receive health coverage, either directly or as a spouse or other dependent. We found that while access to same sex-spousal coverage through ESI is increasing, it remains significantly less common than the offer of opposite sex spousal coverage. In 2018, nearly two-thirds (63%) of employers offering health insurance to opposite sex spouses also offered coverage to same sex spouses and the share of employees with such access has increased over time so most (88%) now have access. These increases follow two Supreme Court rulings ( United States v Windsor and Obergerfell v Hodges) which changed the legal landscape for same-sex couples, ultimately guaranteeing the right to marriage nationwide and paving the way for wider access to health insurance through the workplace. Still, neither court decision requires private employers to offer this benefit and tracking access through ESI remains important.

Findings

Firms Offering

Employer health benefits for married same-sex spouses are becoming more common, but still lag behind benefits for opposite-sex spouses. Learn more in this @KaiserFamFound data note

In 2018, nearly two-thirds (63%) of firms offering health insurance coverage to opposite-sex spouses also provided coverage to same-sex spouses, a significant increase from 43% in 2016 (see Figure 1). The share of firms reporting that they do not provide such coverage (6% in 2018) also declined significantly from 2016 (when it was 16%). Just under a third (31%) of firms reported they had not encountered this as a benefits issue, a finding driven by small employers (those with fewer than 200 workers), who represent the majority of employers overall (98%).

The likelihood of employers offering both opposite sex spousal coverage and same-sex spousal coverage increases with firm size (see Figure 2). Large firms (those with 200 or more employees) were more likely to offer coverage to same-sex spouses compared to smaller firms (87% vs 62%). Almost nine in ten (87%) large firms with opposite-sex spousal coverage offered such coverage, 9% did not, and 4% reported they had not encountered this benefits issue. Among the largest firms (those with more than 1,000 workers), 93% offered coverage to same-sex couples. By contrast, just 62% of small employers (3-199 workers) offered coverage to same-sex spouses. Six (6%) percent did not and 32% said they had not encountered it.

Covered Workers

While the majority of firms in the United States are small, the majority of covered workers are employed by large firms (200 or more workers) (see Figure 3). In 2018, among employees who worked at firms offering opposite-sex spousal health benefits, 88% also had access to same-sex spousal coverage, up significantly from 84% in 2016 and 2017 (see Figure 4). Six percent (6%) did not have access to this benefit, and 6% worked at firms who reported they had not encountered this benefits issue.

As with firms offering, the share of employees with access to same-sex spousal coverage increases with firm size (see Figure 5). Most covered workers (95%) at large firms (those with 200 or more employees) who have access to opposite-sex spousal coverage also have access to same-sex spousal coverage. Just 5% did not, and 1% worked at firms that reported they had not encountered the issue. Among workers at the largest firms (1,000+ workers), nearly all (97%) had access to same-sex spousal coverage.

Workers at small firms offering opposite-sex spousal coverage were less likely to have access to health insurance benefits for same-sex spouses, though a majority did (72%). Nine percent (9%) did not have access to this benefit and another 19% worked at firms that report they have not encountered this issue.

Domestic Partner Benefits

Prior to the Supreme Court decisions guaranteeing the right to marriage for same-sex couples, domestic partnership benefits provided an important way for same-sex couples to gain access to coverage. Some have raised questions about whether federal and state recognition of same-sex marriage would diminish domestic-partnership benefits but, as was the case in 2016 and 2017, we found no statistical difference between the share of large firms offering same-sex domestic partner health coverage in 2018 compared to 2012, among large firms offering health benefits. Further, almost all (96%) large firms offering same-sex domestic partner health benefits also offer same-sex spousal benefits; 66% of large firms offering same-sex spousal coverage offer same-sex domestic partner coverage. Additional data on domestic partner benefits can be found in the full EHBS survey.

Conclusion

These findings indicate that access to employer coverage for same-sex spouses is increasing in the U.S., though it still is significantly less than access to opposite sex spousal coverage.. Coverage varies significantly by employer size, with employees at small firms being less likely to have access to same-sex spousal coverage and the largest employers almost uniformly offering this benefit. In some cases, lack of access to this benefit could be a policy decision though that appears to be declining, with smaller shares of firms saying they do not provide same sex spousal coverage Going forward, it will be important to monitor access to same-sex spousal coverage in the workplace over time and against changes in the legal landscape.
Methods

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Access to Employer-Sponsored Health Coverage for Same-Sex Spouses: 2018 Update

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Using the latest data from our annual Employer Health Benefits Survey (EHBS), we assessed access to employer sponsored health insurance (ESI) coverage for same sex spouses in 2018, as well as trends over time; ESI remains the primary way people in the U.S. receive health coverage, either directly or as a spouse or other dependent.

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Not all employers offer health insurance benefits to same-sex couples. Some employers still include discriminatory policies in their health insurance plans for transgender people.

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If the address matches an existing account you will receive an email with instructions to reset your password.

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June 15, 2020, Supreme Court ruled that Title VII of the Civil Rights Act of 1964 prohibits employment discrimination against LGBT people.Office for Civil Rights could withdraw the rule or clarify interpretation of "sex" nondiscrimination.

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If the address matches an existing account you will receive an email with instructions to reset your password.

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LGBT people; inclusive of trans people

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In the 1960s many gay and lesbian advocacy organizations were formed. They met in secret to avoid arrest, and the only public places gay men and lesbians could meet were gay bars. Stonewall Inn in Greenwich Village was raided by the police in 1969. The Stonewall Riots occurred for a week, paving the way for the first gay rights associations and pride marches.

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Issues: Understanding Controversy and Society - Username

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Welcome to Issues: Understanding Controversy and Society

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The gay rights movement can be traced to the years after World War II. San Francisco, Los Angeles, and New York saw a large increase of gay people forming their own communities and demanding equal rights. However, at that time, openly gay men and women faced discrimination in housing, employment and other social areas, as well as violence.

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Issues: Understanding Controversy and Society - Username

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Welcome to Issues: Understanding Controversy and Society