Mental exams denied in transgender coverage case
TALLAHASSEE, Fla. - Two minors who are plaintiffs in a challenge to a state rule prohibiting Medicaid coverage for gender-affirming care for transgender people won’t have to undergo “mental examinations” as requested by Gov. Ron DeSantis’ administration, a federal judge ruled Monday.
Lawyers for the state Agency for Health Care Administration, which largely oversees the Medicaid program, last month asked U.S. District Judge Robert Hinkle to allow evaluations of patients identified as “Susan Doe” and “K.F.”
But during a telephone hearing Monday, Hinkle said the state failed to show the need to subject the children to the two-hour evaluations.
“If you want to know whether these plaintiffs need this care, probably the crucial place to start is with the treating physicians who said they need this care,” Hinkle said, noting that the state hasn’t sought to depose the plaintiffs’ doctors. “My conclusion is these minors should not be compelled to undergo the requested examinations.”
The DeSantis administration last summer approved a rule to stop Medicaid payments to medical providers for such treatments as puberty blockers, hormone therapy and gender-reassignment surgery after deciding the treatments are “experimental.” The costs of such surgeries, services and medications can run to thousands of dollars per month.
Four transgender plaintiffs, including Susan Doe and K.F., filed a federal lawsuit challenging the rule, alleging treatment for gender dysphoria is “medically necessary, safe and effective” for transgender children and adults. The federal government defines gender dysphoria as clinically “significant distress that a person may feel when sex or gender assigned at birth is not the same as their identity.”
In the lawsuit, parents of the children diagnosed with gender dysphoria expressed concern that the changes to the Medicaid program would have a negative effect on their children’s mental health and could even lead to attempted suicide.
In a motion filed Jan. 17, attorneys for the DeSantis administration requested evaluations “to confirm whether or not plaintiffs suffer from gender dysphoria” and “whether comorbidities, such as depression and anxiety, may be the root cause of plaintiffs’ emotional distress.”
Hinkle initially rejected a request to have South Carolina psychiatrist Geeta Nangia perform the evaluations but gave the state another chance to show how findings from exams would affect “the controlling substantive issue of whether treatments at issue are experimental.” The judge also issued an order in November saying that none of the plaintiffs would be required “to submit to an examination by a transgender denier or skeptic.”
The state submitted a renewed request for the evaluations on Jan. 30, proposing that Louisiana-based psychiatrist Joshua Sanderson conduct the exams. Sanderson in court documents said he believed medical treatment for gender dysphoria should be delayed until adulthood and that such treatments are “experimental” for all patients.
Mohammad Jazil, an attorney who represents the state, told Hinkle during Monday’s hearing that the plaintiffs have alleged they need the treatments to “alleviate or at least improve their mental anguish” and that “denial of the services would adversely affect their mental condition.”
“That may well be true, but I don’t quite know that yet,” Jazil argued.
Evaluations could show if the “minors have comorbidities that can’t be disentangled from gender dysphoria” or if the treatments they are seeking “would exacerbate” some other mental health issues.
“That’s another stick in my bundle as I try to show that it was reasonable for the state to conclude that the puberty blockers, which are the focus for the minors, are experimental,” he said.
But Omar Gonzalez-Pagan, an attorney with Lambda Legal representing the plaintiffs, urged Hinkle to deny the request.
“I don’t think that there has been any articulation in either a motion or today’s recitation before the court as to why it is absolutely necessary for there to be invasive and intrusive examination of two minor, 13-year-old plaintiffs,” Gonzalez-Pagan said. “There is no proven necessity here.”
In his verbal ruling Monday denying the state’s request, Hinkle said Sanderson has “already made up his mind about the need for the treatment” at the heart of the legal challenge.
“When you analyze the relative burden against the likely benefit, the balance comes out on the plaintiffs’ side of the scale. This examination is unlikely to provide much benefit,” the judge said.
Since the experts offered by the state claimed that they had examined “thousands” of patients diagnosed with gender dysphoria, evaluating two more patients wouldn’t alter their views, Hinkle added.
“The idea that two more anecdotes would affect the opinion of the defense experts just doesn’t make much sense,” he said.
The rule went into effect in August, and Hinkle refused in October to issue a preliminary injunction to block it.
DeSantis, who is widely considered a potential frontrunner in the 2024 Republican presidential contest, and his allies have taken a number of steps to curtail gender-affirming treatment. For example, at the Department of Health’s request, state medical boards recently advanced a proposal to prohibit Florida doctors from using puberty blockers, hormone therapy or surgery to treat children diagnosed with gender dysphoria.
The governor, who frequently brings up the issue during public appearances, fiercely defends the state’s approach.
“They’re doing sex change operations and … so we actually have young adults who went through this when they were minors and they’re saying this is a huge mistake. And in fact it’s not evidence-based, when you start talking about sex changes and puberty blockers. So … (if) you’re performing those procedures on these minors, you’re going to lose your medical license here in Florida. So that is happening,” he told reporters in Bradenton last week.
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